'm 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


Santa 


on.ijA  ri\'i:  srij(ii:ijv 


Nosi:.  'I'liijoA  r.  AM)  i:ak* 


*anta  mon 


Ol'KIIATIVK  SIKMiKKV 


AOSi:.  TIIK'OAT.  AM)   KAK' 

I'OIJ    I.AK'VXCOI.OCISTS,    lv'lll\nl,(t(;iS'rs,    OTOlJXIlSTS, 
AND  srHCKdXS 


M.WAI      W.    I.(i|-;i".,    A.M.,   .M.I). 

PROFESSOR  OF    i:.\U,   XOSi;  AND   TIlRc).\r    lJlSi:.\Si:S    IN    Sr.    LOIKS   l-NUERSITY 

IX  COLLABORATION   WITH 

Joseph   C.    Heck.   M.I).,   George   \V.   Crilc.   M.D.,    William    II.    Ilaskin.    M.n..    Robert    Levy.    M.D.. 

Harris   P.    Moslicr,   M.D.,  George  L.    Richards.    M.U,   Gcarge    H.    Shainb.niRh.   .M.D., 

and  George   H.   Wood,  M.D. 


l.\  TWii  \n|,r,MES 


VOL.  I 


Foi  i;  III  \ni;i:i>  wn  mm:  ii.i.t  stumioss 


f<T.  Loris 

C.  V,  MOSBY  <(i.MI'.\\V 
1917 


Copyright,  1917. 

(All  Rights  Reserved.) 


Press  of 
Mosby    Comfo 
St.  Louis 


v\{\:\.\(  K. 

'V]u>  \\()i-l<  was  uiiiliTlaki'ii  ;il  \\\r  .-im^ot  ion  of  m:iii\'  (■()ll(';ij::iies, 
with  nil  little  iiii>-i\  iiii;-  (in  tiir  iiai1  (if  tln'  antlnir.  'I'n  li.u'lilt'ii  tlio 
liurdi'ii  and  to  iiiakc  tlic  imlilicatiuii  moiv  cl'lVrl  i\  r.  it  \\  a>  ili\  idcd  ainoufr 
collaliovntors  wlio  were  ^pi'cially  (|ualifi('il   fm-  the  a>^ii;ncil  topics. 

Till'  (•ndi'avoi-  lias  liccn  to  |iicM'nt  tin-  (i|ii'rat i\c  sni-.i;cr\'  (if  tlic 
iiosi',  throat  and  i-ar,  uuacconipauicd  liy  an\'  discussidn  (iT  patliolo.i;}', 
etiolo<iy  or  svniptoiiiatolojiy.  The  inetliod  of  o])('iatiii.!;-,  the  indica- 
tions, file  contraindications,  aftcr-t rcatin(Md  and  i-csults  Innc  liccn  con- 
sidci-i'd  pai'ainount  for  the  iini|i(iM's  (if  this  v.dik. 

'Phf  illiislratidns  ai-c  pi'act  icall\-  all  (iriuinal.  the  niajdiilv  (if  tlicin 
licinL;-  ih-awii  expressly'  Inr  this  wdrk.  'I'licy  arc  planned  td  niak'c  llie 
text  cleai'  witlidiit  tdd  xi'eat  a  saci-ilice  df  detail. 

'Hie  lifsl  \(iluiiie  deals  with  the  iiKiie  i^ciieral  subjects,  sucli  as 
the  .-uruical  anatdiny  di'  the  nd>e.  thidat  and  ear.  the  extci-nal  sni'ffcry 
of  the  throat,  the  direct  e\aiiiinatidii  (if  the  lai-ynx,  ti'acliea,  lirondii, 
esopln\<iUs  and  stoniach.  and  tlie  opeiations  made  possilile  through 
its  a.u'ency,  and  the  ]ilastic  sur,c('i\\'  ol'  the  nose  and  eai'. 

Vohune  II  is  td  lie  dc\(ited  t(i  the  iiKirc  specialized  surgery  of 
the  nasal  ca\'ilies.  the  jjharynx  and  larynx,  wiiicli  has  heen  de\'eloped 
(lnrin<;'  the  years  of  laryng'olofi'ic  and  otohiLiic  acti\il\'.  since  the  laryn- 
goscope was  devised. 

(Iratefnl  acknowledgment  i>  here  made  In  I  lie  many  w  lin  have 
liy  Iheii-  elTiirt-,  ad\ice  and  eiicunraucmeiil  reiidere(|  this  pultlication 
possible,  to  .Mr.  .\.  Schwilalla,  S.  .1..  w  Im  \\a,-  (if  L^reat  assistance  in 
reviewing  tlie  text,  to  the  cdllalidraldrs,  and  Id  the  pulilishers.  whose 
]iatie!ici^  lias  been   mo.-t    cdinniendable. 

II.    W.    I.. 


coNiHii'.r  i()i:s  I'o  \{)\..  I. 

JOSKIMl  C.  HKCK,  M.  I)..  Cuk  aco. 

Profossor  of  Otulo-y,  Khincln^v  mihI  L;ir\  ii^'iiln- v,  friiviTsilv  (if   Illinois. 

GEORGE  W.  CHILE.  M.  D.,  Cleveland. 

Professor   of   Snri;(My,   Wcstoni    Rosorvp   Tniversity 

H.^NAU  W.  I.OKH.  M.  1)..  St.  I.oits. 

Profi'S.sor  of    K:ir,   Xo,-ii>  ;iiiil    Tliriiat    JJiscii.scs,   St.   l>oMis    I'liivorsity. 

HARRIS  F.  MOSHER,  M.  D..  Boston. 

Assistaiil    PnilVssor  of   r,nr.vimoloi.Ty.   Ilurvard    Mrdiciil   Sc-lio.il. 

GEORGE  E.  SHAMiiAUGM.  M.  I).,  (hk  aco. 

Associate  Professor  of  Laryiijioloj^y  and  Ololo^^y,  Kiisli  Moillral  ('ollooc. 

GEORGE  15.  WOOD,  .M.  I)..  I'liii.Anii  riiiA. 


CON  I  K.N  I  >. 

oil  A  I'T  i:  H     T. 

TIIK  Sri{<;Ff.\F-  .WA'in.MV    i.l'  'IIIK   N'nsi;. 

PAGE 

Externnl  Xosf 1 

Xasal    Cavities    3 

Floor  of  the  Nose— Septum  Xasi — Roof  of  tli(!  Xoso — Kxteriial  Wall  of  tlic  Xobc 

— Tlie  Clioana;. 
Accessorv  Sinuses  of  the  Xo.se T 

Frontal  Sinus — Maxillary  Sinus — Etlirnoii]   Cells — Spliciioiil   Sinus. 
Variations  of  the  Sinuses  in  Size  and  Shape '■'''* 

Frontal     Sinus — Maxillary     Sinus — Etlimoid     Cells — Ethmoid     Labyrinth — Anterior 

Ethmoid  Cells — Posterior  Ethmoid  Cell.s — Sphenoid  Sinus. 

Supcrfieial  Area  and  Cubical  Capacity  of  the  Sinuses. . .  .• 36 

Optic  Chiasm  and  Xerve 40 

Xa.«olaprimal  Duct —       50 

Hypophysis    (Pituitary   Body) 52 

Vascular  Supply   '- 

Arteries — Veins. 
Innervation     "  ' 

SjTnpathetic  System. 

C  II  A  P  T  F.  H    II. 

BT'ROirAL  AXAT0:MY  of  TJIE  PHARYXX,  LAHY.XX,  AXn  XECK. 
THK  PHARVX.X. 

Xasopharynx    5;j 

Pharpigeal  Tonsil. 

Oropharynx     59 

Palatal  or  Faueial  Tonsil — Pillars  and  Lateral  and  Posterior  Walls. 

Laryngopharynx "-"^ 

L^TTiphatics  of  the   Phai-j'nx 64 

Xen-es  of  the   Pharynx 65 

Structures   of    the    Pharj-ngeal    Wall 66 

Superior  Constrictor  Muscle — Middle  Constrictor  Mu.scle — Inferior  Constrictor 
Muscle — Palatophar>Ti{feal  Muscle — Stylopharyngeus  Muscle — Palatoglossus  Muscle 
— Azygos  XJ\-ulse  Muscle — Levator  Palati  Muscle — Tensor  Palati  Muscle. 

THK   LARVX.X. 

Superior  Division   "" 

Ventricular  Bands. 

Middle  Division "'' 

Inferior  Division    "1 

Cartilages  of  the  Lar>-nx "1 

Cricoid  Cartilage — Arytenoid  Cartilages — Thyroid  Cartilage — Epiglottic  Cartilage — 

Lesser  Cartilages. 

(Xi) 


Xll  COXTEIfTS. 

PAGE 

Articulations    niiil    Ligament*    of    the    Larynx ~'i 

Joints — Ci'icotliyroid  Membiaue — Thvroliyoiil  Meniliranr — I n I'cricir  Tli.vroarytcndiil 
Ligament — Superior  Thyroarytenoid  Ligament— Ligaments  of  tlio  Epiglottis. 

Muselcs  of  the  Lar^^lx   75 

Cricothyroid  Muscle — Posterior  Cricoarytenoid  Muscle — Arytenoid  Muscle — Lateral 
Cricoarytenoid  Muscle — Thyroarytenoid  Muscle — Kxtenial  ThNToar^-tcnoid  Muscle 
— Thyroepiglottic  Muscle — Internal  Thyroarytenoid  Muscle — Action  of  the  Muscles. 

Nerve  Supply  of  the  Larynx 70- 

Superior  Laryngeal  Nerve — Internal  Lai-yngeal  Sei-v — External  Laiyngeal  Nerve 
— Recurrent  or  Inferior  Larj-ngeal  NeiTe. 

THE  LYMPHATIC  SYSTEM  OF  THE  NECK. 

LjTnphatic  System  of  the  Neck 70' 

Suboccipital  Group  of  Glands — Mastoid  Group — Parotid  (iroup — Suliparotid  (ilamls 
— Submaxillary  Group — Facial  Glands — Submental  Group — Retrophar\nigeal  Group 
— Descending  Cervical  Chain  of  Lymph  Nodes — Ac<?essoi7  or  Superficial  Descend- 
ing Cervical  Chain — Supraclavicular  Group  of  Lymph  Glands. 

TOPOGRAPHIC   ANATOMY   OF   THE   ANTERIOR    CERVICAL    TRIANGLE. 

Topographic  Anatomy   of  the  Anterior  Cervical  Triangle 85 

Sternocleidomastoid  Muscle — Submaxillary  Salivary  Gland — Digastric  Muscle — 
Stylohyoid  Muscle — Facial  Nerve — Internal  Jugular  Vein — Hypoglossal  Nerve — 
Common  Carotid  Artery — Omohyoid  Muscle — External  Carotid  Artery — Superior 
Th\Toid  Artery — Ascenduig  Phar_\-iigeal  Artery — Lingual  Artery — Facial  Artery — 
Occipital  Artery — Posterior  Auricular  Artery — Internal  Maxillaiy  Artery — Super- 
ficial Temporal  Artery — Internal  Carotid  Artery — Pneuniogastric  or  Vagus  Nerve — 
Superior  Laryngeal  Nerve — Recurrent  or  Inferior  liaryngeal  Nerve — Spinal  Ac- 
cessory Nerve — Glossophar^nigeal  Nerve — Pharyngeal  Plexus. 

CHAPTER    III. 
THE  SURGICAL  AXAT0:\1Y  OF  THE  EAR. 

Introduction     99' 

Development  of  the  Temporal  Bone 99- 

Meatus  Auditorius  Externus   1 02 

Processus   Mastoidcus    108 

Cavum   TxTiipani 116 

CHAPTER    IV. 

EXTERNAL  OPERATIONS  OF  THE  LARYNX,   PHARYNX,   UPPER 
ESOPHAGUS,  AND   THACHEA. 

Special  Difficulties  and  Dangers  125 

Pneumonia — Local  Infection — Mediastinal  Abscess — VagitLs — Reflex  Inhiljition  of 
the  Heart  and  Resjiiration  Through  Mechanical  Stimulation  of  the  Superior  Laryn- 
geal Nerves — Selection  ami  Care  of  Tracheal  Cannula. 

Operations  on  the  Trachea 130' 

Tracheotomy — Emergency  Tracheotomy — Planned  Tracheotomy — Tracheal  Tube — 
After-care  of  the  Patient — Closure  of  a  Tracheotomy — Cicatricial  Stenosis  of  the 
Trachea. 


CONTENTS.  XI 11 

PACK 

Surgery  of  tlio  Larynx l-'iS 

Laryngectomy  for  Intrinsic  Cani-er — Aiu^stlu'tic  in  Laiyiigectomy — Tediuic  of 
Larynuectoniy — T'lxtrinsic.  Cancer  of  the  Larynx-  8leno.sis  :if  tlie  Larynx. 

Surgery  of  the  Pharynx  and  Esophagus 148 

Cancer  of  the  Pharynx  and  Esophagus — Excision  of  tlic  Tonsil  for  Cancer — Cancer 
of  the  Pilhirs — Stenosis  of  the  Pharynx — Esopliagostomy — Cancer  of  the  Esophagus 
— Diverticula  of  the  Esophagus. 

CM  A  I'  T  \:  K     V. 

I..\I{Y.\(;<»SC(>I'V.     TU'At'llKdSi  (H'^',     I'.lv'oM  I  K  iS(  ol'V.     |-;s(  tl'1 1A(  ;(»S 
corv.  AND  CASTUoSCdl'V 

THE   DIRECT   K.\ AMI.NATION   OF   TJIK  LAKYXX. 

General   Considerations    155 

Historical — Contraindications — Cliciice  of  tlie  .\nestheti( — Cocainization — Difficulties 
iif  the  Examination. 

Metliod   of   Making  the   Direct    Examin:itii>n l.jS 

Passing  the  Speculum  from  the  Conu-r  of  tlie  Mouth — Direct  Examination  with 
Counter  Pressure — Direct  Examinati(pn  Fndev  Ether — Instruments  for  Direct  Ex- 
amination— Inhalation  of  Oxygen. 

Suspension  Laryngos-copy   1G7 

TKAfllEOI'.RO.VCIIOSCOPY 

Lower   Tracheobronchoscopy    170 

Contraindications  to  Lower  Traclieolironchoscopy — Anesthesia — I'usition  of  the  Pa- 
tient— Method  of  the  Examination — Tlie  Endoscopic  Picture — Interpretation  of  the 
Endoscopic  Picture — Choice  of  the  IJpiiei  or  Lower  Route — Dangers  of  Rronchoscojiy 

_Ase].si^— Size  nf  the  Tul.es. 

I'.KOXCJIOSCOPV. 

Lower    Bronchoscopy    ISO 

T'ppcr    Bronchosco]iy    1S7 

Anesthesia — Method  of  Performing  Upper  Bronchosco])y- — Tntro<luc.tion  of  the  Bron- 

cliDscope    with    the    Patient    Lying    on    His    Back — Up]ier    Broncliosco]iy   with    the 

Jackson    Tulmlar    Speculum    and    the    .Tack.son    Bronch(isco])e — Introduction    of    the 

Bronchoscope  with  the  Open  Speculum. 
Examination   in  Children 1  SO 

Instruments — Direct   Lar™goscopy — Method    of    Examination — Lower   Bronchosco]iy 

— Upper  B'ronchoseoi)y. 
I  nstruments  for  Bronchoscopy 101 

Jackson       Tubular      Sjieculum — Briinings'       Elongating      Broncliosco])C — Briinings' 

Elongating     Forceps — Batteries — Asjiirator     for     Removing     Secretions — Acquiring 

Skill. 
Direct  Laryngoscopy  for  Diseased  Conditions l<l(i 

Malignant   Disease — Non-Malignant    Disease    of    the    Larynx — Tuberculosis    of    the 

Laryn.K — Inflammatory    Diseases — Malformatinns    of    the    Larynx.    Congenital    and 

Acquired. 

Retrograde    Laryugosco]iy    2(1(1 

Tracheobronchoscopy  in  Dis<>ases  of  Trachea  and   Bromlii '2(H) 

Stenosis  of  the  Trachea — Treatment. 


CONTEXTS. 


RK.MOVAL  OF  FOREIGX  BODIES  FROM  THE  LARYNX,  TRACHEA 
AND  THE  BRONCHI. 

F(iroii;ii   Hoilics   in   tlio   Larynx 202 

Removal  of  Foroign  Bodies  from  Trachea  and  Bronclii 203 

Choice  of  the  LTppe,-  or  Lower  Routx- — Indications — Dangers — Danger  frnrn  Leav- 
ing Foreign  Body  Alone — Results — Symptoms — Diagnosis — Pliysical  Signs — Loca- 
tion— Teclmic  of  Removing  Foieign  Bodies— After-effects  of  Removal  of  Foreigii 
Bodies. 

ESOPHAGOSCOPV. 

Esophagoscopy     o-[q 

History — Anatomy — Structnre  —  Lymphatics  —  Position  —  Direction  —  Diameter — 
Length  of  Esojdiagns— Distensibility — Subphrenic  Portion  of  the  Esophagus — Move- 
ments of  the  Esophagus — Measurements  of  the  Esophagus — Contraindications  to 
Esophagoscopy — Anesthesia — Instruments — G<>neral  Examination  of  the  Patient — 
■  Technic  of  Esophagoscopy  Under  Cocain  Anesthesia — Position  of  the  Patient 
Introduction  of  the  Esophagoseope  by  Sight — Introduction  of  the  Esophagoscope 
by  Means  of  a  Flexible  Mandrin  or  Bongie — Introduction  of  the  Esophagoseope 
Under  General  Anesthesia — Use  of  the  Adjustable  Speculum  for  Introduction  of 
Esophagoseope — Passing  the  Jackson  Esophagoscope  by  Sight — Passing  the  Oval 
Tube  by  Sight — Passing  the  Esophagoscope  by  Aid  of  a  Mandrin  or  Flexible  IViugie 
— Appearance  of  the  Normal  Esophagus. 

THE   DISEASES  OF  THE   ESOPHAGUS. 

Acute    Intlaniniation     030 

Stenosis  of  Esophagus  Due  to  Cicatrices ...     232 

Location  of  Strictures — Diagnosis  and  Trcntmcnf  of  Eso|iliiigeal  Strict\irps— Cases 
of  Stricture — Use  of  a  Thread  as  a  Guide  in  Esophageal  Strictures — .\fter-care 
of  Strictures  of  the  Esophagus. 

Spastic  Stenosis  of  the  Esophagus 240 

Esophagospasm — Cardiospasm— Phrenospasm. 
Benign  New  Growths  of  the  Esopliagnis 247 

Treatment  of  Benign  New  Growths. 

Malignant  New  Growths  of  the  Esophagus 248 

Symptoms  of  Cancer  of  the  Esophagus — Diagnosis  of  Cauc<'r  of  the  Es(i]ihagiis— 
Diagnosis  and  Treatment  of  Cancer  of  the  Esophagus. 

Compression  Stenosis  of  the  Esophagus 254 

Inflammation  and  Ulceration  of  the  Esophagus 2.54 

Chronic  Inflammation  of  the  Esophagus— Ulceration  of  the  Esophagus. 

Neurosis  of  the  Esophagus 0.5,3 

Sensory  Neurosis  of  the  Esophag-iis— Paralysis  and   Paresis  of  tlie  Esojijiagns, 

Congenital  Anomalies  of  the  Esophagus 2.57 

Congenital  Stricture  of  the  Esophagus— Divcrticnhini. 

Dilation  of  the  Esophagus ogp 

Foreign  Bodies  in  the  Esophagus 261 

Places  Wliere  the  Foreign  Bodies  Lodge— Procedure  to  be  Followed  in  Cases  of 
Foreign  Bodies— Choice  of  the  Anesthetic— Coins  ahd  Buttons  in  the  Esophagus— 
The  Bristle  Probang— Pins  in  the  Esophagus— Safety   Pins  in   the   Esopliagus. 


COXTEXTS.  NV 

OASTROSf'OI'V. 

PAfiK 

Gastioscopy    271 

History — Uscfuliioss — Inslnimoiits — Tocliiiic  of  Gaslroscopv — I'ositioii  of  llio  Pa- 
tient— Passing  the  Gastroscopp — Area  of  tlio  Stoniacli  Wliii-li  Can  lio  Kxploied — 
Contraindications — Dangers — Uiflficulties. 

Tlio   Stomach   as   8e<'n    Tlirongli   the   Ciastroscope 270 

Xnniial  StoMKii'h— irovonients  of  the  Stoniaeli—C.astritis— Peptic  Ulcer— Malignant 
IMseasi's  «f  the  StoniacIi— Gastroiitosis  and  (iastrectasia. 

ClI  A  I'T  K  R     \-  T. 

PLASTIC  srKdEHV  (»F  TIIK  XOSK  AM)  EAR. 

( ieneral    Considerations    27f> 

History — Important  Factors — Covering  Defects — Recording  Cases  Before.  During 
and  After  Correction. 

HHIXOI'I^ASTV. 

Rhinoplasty    28S 

Classification  of  Xasal  Deformities— Jiethod  of  PrnciMlnres  in  Xasal  Deformities 
and   Malformations. 

Correction  of  Unilateral  and    IMutial    l)efi<-ieiicies  of  the  Xose 29t 

Legg's  Ojieration — Koenig's  Operation — A'on  Ksmarch's  Operation — Von  Langen- 
heck's  Operation — DietTenliach's  Operation — Von  Esmarch 's  Operation — Busch 's 
Operation  for  Partial  Loss  of  Tip  and  One  Side  of  Nose — Nelaton 's  Operation — 
Sonne's  Operation. 

Correction  of  Total  Loss 295 

Helferich's  Operation   (French  Method^. 

Correction  of  Sunken  Bridge,  Upturned  Loliule  or  Tip,  and  Sadill(>  Imck 29S 

Roljerts'  Operation  for  Sunken  Bridge  with  U]itiniic,l  Lohnli-  or  Tiji  of  Xose — 
Roberts'   Operation   for  Sunken   Saddle-back   Xose. 

Formation  of   a   Xew   Colnmella 301 

Dieflfenliach 's  Operation — From  the  Dnrsiim  of  X'os<'  (Hindoo  ^re1Ilo(^ — Lexer's 
Operation  for  Formation  of  Columella  (from  Mucous  Membrane  uf  the  U]i|ier 
Lip). 

Dalian  or  Tagliacozzi  's  Method   .■!0,> 

Isracd's  Operation — DietfVnbacli's  Operation — Xclaton  "s  Operation. 

Hindoo    or    1  mliau    Method 31  f) 

Thiersch's  Operation  for  Total  Loss  <if  Xose — Xelaton 's  Operation  for  Total  Loss 
— Koenig's  Operation  for  Subtotal  Loss — Nelaton's  Operation  for  Subtotal  Los.s — 
Von  Langenbeck's  Operation  for  Collapsed  X'ose — Sc.himmelbusch 's  Operation  lor 
Total  Loss — Scliimnielbusch's  Operation  for  Saddle-back  X'ose — Sir  Watson  Cheyne's 
Operation — Von  Hacker's  Operation — Sedillot's  Operation  for  Total  Loss. 

Double   TransplantatujH   Mi'thcl    .^27 

Steinthal's  Operalioii   fur  Total  Loss— Kausch 's  0|ierati(ui    for  ColIa|.sed   Xose. 

Finger   Method 330 

Watt's  Operation  for  Subtotal  Lciss- WolUowitsch 's  Operation  for  Total  Loss— 
Von  Esmarch "s  Operation   for  Collajiseil   Xose,  Etc. 

Clavicle  Method    335 


XVI  ("ON'TKXTS. 

PAOE 

Implantation   Mi'tluiil    337 

Israel's  Oporatiiiii  for  SaililU'-liai-k  Nose — Gocidalr's  ()|icra.tioM  fur  Depressed  Nose 
— Ouston's  Operation  for  Depressed  Nose  Below  the  Bridge — Carter's  Operation 
for  Saddle-back  Nose — Bock's  Operation  for  Saddle-back  Nose — Walshau's  Opera- 
tion for  Collapsed  Ala? — Lambert's  Operation  for  Collapsed  Alse. 

Paraffin  Injections  in  Nose  and  Ear  Deformities 344 

History — Indication — Results — Technic  of  Injections — Injections  in  Nasal  Deflcien- 
cies — Injections  in.  Ear  Deficiencies — Injections  in  Collapsed  Alie. 

Kednction   Metliod    354 

.Joseph's  Operation  for  Reducing  Hump,  Length,  Width  of  Nose,  and  Large  Nos- 
trils— Kolle's  Operation  for  Hump  Nose — Beck's  Operation  for  Hump  Nose — Bal- 
lenger's  Operation  for  Hump  Nose — Biallenger's  Operation  for  Long  Nose — Roe's 
Operation  for  Hump  Nose,  Twist  and  Broad  Ala  or  Large  Nostrils — Roe 's  Operation 
for  Broad  Ala'  ov  Large  Nostrils — Beck's  Operation  for  Hump  Nos<.' — Kolle's 
Operation  for  Long  Tip  Nose. 

Prothetie  or  Artiticial  Noses 362 

Artitieial  Supports. 

Orthopedic   Method    362 

Operations  for  Closing  Perforating  Septum 364 

Cloldstein's  Operation — Hazeltine's  Operation  for  Perforation  of  Septum — Gold- 
smith's Operation  for   Closure  of   Septal   Perforations, 

OTOPLASTY, 

Classifications  Accoiding   to   Kollr 366 

General   Consideration    367 

General    Classification     ,167 

Usual  Operation  for  Maorotia — Parkhill's  Operation  for  Maerotia — Cheyne  and 
Burghard's  Operation  for  Maerotia — Goldstein's  Operation  for  Maerotia — Gold- 
stein's Operation  for  Projecting  Ear — Beck's  Operation  for  Roll  Ear  or  So-called 
Dog  Ear — Szymanowski  's  Operation  for  Reconstructing  an  Auricle — Beck  's  Opera- 
tion for  Synechia  or  Auricle  to  the  Mastoid  Squama — Roberts'  Operation  for 
Absence  of  Ear — Simple  Operation  for  Colobomata — Green's  Operation  for  Colob- 
omata — Monk's  Operation  for  Prominent  Ear — Kolle's  Operation  for  Projecting 
Ear. 

Postauricular  Deficiencies  or  Retroauricular  Fistulie 378 

Trautmann's  Operation  for  Closure  of  Posterior  Deficiencies — Von  Mosetig-Moor- 
hoff  Operation — Goldstein's  Operation — Ear  Prothesis. 

NEUROPLASTV  FOR  FACIAL  PARALYSIS. 

Neuroplasty  for  Facial  Paralysis 353 

Spino-Faeial  and  Periphero-Spinal  to  Descendens  Hy])oglo.ssi  Anastomosis 384 

Facial-Spinal  Anastomosis — Facial-Hj-poglossal  End  to  Side  Anastomosis — Facial- 
H\T)oglossal  End  to  End  Anastomosis — Myeloplasty  for  Facial  Paralysis. 


II.Ll  S  I'KA  I  IONS. 

FIG.  l..\OK 

1.  Tlio  ciiitilaKi's  cif  the   nose;    lalei:,l   vi.nv 2 

2.  The  ciirtilaiios  of  the   nose ;   ajitevior   view 2 

.'!.     The    orifices    of    the    nose    showing    a    dissfctiun    of    tlie    ernia    niedialia    of    tlie 

cartilasines  alares  Tuajores    Z 

4.  Floor   of   the  nose 4 

5.  The  septum   nasi 5 

(j.     The  right  outer  wall  of  thr  nose (1 

7.  Tlie  left    outer  wall   ol'   the   iinse   with   the   conchti    nu'dia  removed S 

8.  The  elioana'  and  anterior  wall  of  the  sphenoid  siiuis  viewed  from  behind it 

9.  Tin-   left   orldt;    bone    relalii.ns ]1 

10.  Left    orliit   with    lione   iCTiupveil    exposing   the   mucosa    of   the  acfcssorv  siimses 12 

11.  Hones  cif  the   nose  and   cubits:   external   |date   over   frontal   siiuises  removed 1.'! 

12.  Floor    of    the    anterior    cranial    fossa;    bony   roof    of    accessory    sinus    removed    in 

pari     14 

i:-,.      Coronal   sei-tion    tlnousli   the   luisi'   and    (U-bit lo 

14.  Rii;lit    lateral    view    of   bones   of   the    face   with   maxillary   sinus   ami    loots   of   the 

teeth    expnsed     17 

15.  Sagittal    secti<ui    through    tlie    light    side   of    nose   and    maxillary    sinus.      l-Ixlernal 

portion     IS 

Ki.     Sagittal  section  thnpugli  the  riglil   side  of  the  nose.      Internal   portion lii 

17.      Sagittal    section    thmugli    the    left    side    id'    the    nose    internal    In    tlial    of    Figs,    b'l 

and    16.      Inner    piutinu 20 

IS.      Sagittal    section    tliroiigli    ll^'    left    side    nf    tlie    nose    internal    In    that    of    Figs.    1." 

and    1(1.      Kxternal    pnrtiim 21 

19.      Coronal    section    through    nose   and    orbil    tliiee    mm.    anterior    to    llie    anterior    wtill 

of   the   sphenoid    sinuses 22 

20-34.     Lateral  and  superior  reconstruction  of  the  accessory  sinuses  of  tlie  nose 25-29 

35-40.     Plaster  c.ii-sts  of  splieiioid  sinuses,  placed  in  situ 34-39 

41-55.     Preparation  showing  relation  of  o]itic  nerve  to  accessory  sinuses  nf  the  iio.se..     40-49 

56.  Right    lateral    wall    of    the    nose    with    exposure    of    the    sacciis    iiasnlacriinalis    and 

ductus    nasolacrimalis    50 

57.  Coronal    section    through   the    sphenoid   sinuses,    removal    of    s<'ptiini    sinuuni    sphe- 

noidalium  and  exposure  of  the  hypophysis 51 

5S.     Median   section   through   face   of  an   adult   tuaii,   showing   the   iiornial    relations   of 

the  structures  during  quiet   nasal   respiration 56 

59.  Xleiliaii    section    tliKiiigli    tin-    face   of   an    infant    one    month    old.   showing    the    rela- 

tions of   the   siructures   during  (piiet    nasal    resjiirtitiou 57 

60.  Transverse   section    through    the    head    of   a    child    mie    month    old    just    in    frniit    of 

the    posterior    idiaryngeal    wall 58 

61.  The  region  of  the  palatal  tonsil 60 

<i2.     Dissection  of  the  region  of  the  palatal  tonsil   from  the  outside d's 

6:i.     Dissection    showing    the    relation    of    (he    tensor     p.alati    ami    the    levator    jialati 

muscles     68 

(xvii) 


XVIII  ILLT-.STRATIOXS. 

no.  PAGE 

04.  The  laU-ral   nxtornal  Hurface  of  thp  laiynx 75 

05.  TIio  muscles  of  the  laryngeal  wall  on  the  poirtciior  aspect 76 

06.  Diaiframs  illu.itrafinf;  close*!  and  open  glottis 78 

07.  Dissection  showing  the  upper  deep  ceirical  lymph  »<»](•« 82 

08.  Superficial  dissection  of  the  carotid  triangle 86 

69.  Dissection  of  the  pes  anserinus  of  the  facial   nervi' 00 

70.  Deep  dissection  of  the  carotid  triangle 01 

71.  The    relation    of    the    palatal    tonsil    to    the    vessels    and    nerves    of    the    carotid 

triangle   96 

72.  Temporal   bone   from   new-liom 1 01 

7."?.     Temporal  lione  from  child  one  year  old 101 

74.     Temporal  lione  from  child  three  years  old lO.T 

7.1.     Temporal  bone  from  child  ten  years  old 10."? 

76.  Frontal   section  through  the  adult  temporal  I'one;   the  anterior  jiart  viewed   from 

behind    ■. 104 

77.  Adult  temporal  bone  showing  the  position  of  the  antrum  t>Tnpanicum  and  mastoid 

cells  along  tho  upper  posterior  wall  of  the  extcrrnal  canal 104 

78.  Horizontal  section  through  the  tempor.-d  bone  viewed  from  above 105 

79.  Section  through  mastoid  process  and  oxteriial  canal 1 0.0 

80.  Section   through   temporal   bone,   showing  the  relation   of   the   facijtl   canal   to   the 

fenestra  vestibuli  and  of  the  horizontal  («inal  to  the  antnini 106 

81.  Section  through  te^mporal  Imne,  exposing  the  fa/-ial  canal 107 

82.  .Vdult  temporal  bone,  showing  anatomic  relations  after  a  complete  tjTiipanomastoid 

exenteration    107 

83.  Adult   temporal    bone,   -showing   the   t>7)ical    relation    of   the   linea   tcmjjei'alis    ex- 

tending in  a  liori/ontul  direction  back  from  the  external  canal 108 

84.  Adult  temporal  bone,  showing  the  linea  temporalis  making  a  marked  curve  down 

along  the  posterior  ?)order  of  the  external  meatus  before  turning  backward.  .  .  .  100 

85.  Adult    temporal    bone   showing   the   linea   temporalis   making   a   curve   upward    !it 

the  posterior  margin  of  the  extciTial  meatus 110 

86.  Section  through  mastoid  process,  antmm  tympanicurn,  .-ini]  external  canal Ill 

87.  Pneumatic  type  of  mjustoid.    Larger  «dl.s  arranged  along  the  jieriphory 112 

88-89.     Section  through  temporal  bone.     Section   passes  through  antrum,  veslilnilf  arjil 

interaal  meatus  112 

90.  Section    through     U-m^'n-A     bone,    showing    lelntion     of    the    lioriz.intal     caiKil     ;.im1 

facial  canal  tn  Ihi'  midille  ear  chambers;  also  rcliitioii  of  llie  carotid  and  Imlba?- 

jiigularis   to    the   I'avnm   t\'mpani 11  ■'5 

91.  Section  through  the  mastoid   [irocess,  showing   but   pmti-il    |piiciirriatizatioii 114 

92.  Diplretic  tj'pe  of  mastoid.     ('iiT]i|iletc   !il(>cni-c   of   ipniMinr.-it  ir-   s[rafes.      Anirinn    tyiii- 

panicuni  c^ntract/cd    114 

9.").     Section  through   adult  temporal  bone,  showing  persistence   (jf   infantile  t.v|ie   with 

absence  of  pneumatic  sjiaces  in  the  mast-oid 1 1o 

94.  Section  through  adult  tx'mporal  bone,  showing  the  relations  of  the  carotid  to  the 

cavum  tympani  and  the  structures  in  the  tloor  of  the  recessus  epityinjjanicus.  ...  116 

95.  Section    through    mastoid,    cavum    tympani,    tuba   auditiva,    showing    a    large    tubal 

cell      117 

96.  Sr-clioii   tinougl]  tlir>  ni;istoid  and  tympanic  cavity,  sliowirig  the  relation  of  the  Ijori- 

zoiital    aJid    sii|ierior   (■aMal>*   to   tlic   aatniMi 1  Ti 

!i7.      Ifoiizoiital    section   thr(jii;;h    the   trniporal    bone   scon    fj.uri    Im-Iow 119 


ILLVSTRATIOXS.  XIX 

PAGE 
Section    through    temporal    V)ono,    shonin<;    rplation    of    the    bulbus    jiigularis    to 
cavuiu   tympani  and   relations   of  the  cochlea   and   facial   canal   to   the  ca^^lnl 

tympani     120 

Horizontal  section  through  the  temporal  lione  seen   from  aliove 122 

View  of  the  posterior  aspect  of  the  temporal  bono,  showing  bulbus  jugularis  ex- 
tending to  the  upper  margin  of  the  fietrous  l>one 123 

Tracheotomy  under  local  anesthesia :  novocainizing  the  skin 132 

Tracheotomy.     Incision  through   thjnoid   gland  and  trachea 133 

Tracheotomy.     Xovocainizing  the  trachea  from  within 134 

Tracheotomy.     After  the   operation 135 

LarjTigectomy.     Preliminary  tracheotomy  witli  iodoform  gauze  packing 141 

Larj-ngectomy.     Five  days  after  preliminary  tracheotomy.     Arrangement   of  tube 

for  anesthesia    142 

107.  LarjTigectoniy.     Separation  of  the  larynx  from  the  esophagus 143 

108.  Laryngectomy.     Closure  of  pharyngeal   ojiening 144 

109.  Laryngectomy.     Closure  of  wound  with  iodoform  gauze  packing 14o 

110.  Esophagostomy.     Ample  incision  of  skin  along  the  anterior  border  of  storiiomas- 

toid   mviscle    .  . , 152 

111.  Esophagostomy.     Exposure  of  esophagus    153 

1 12.  Esophagostx)my.     Esophagus  stitched   to  skin    154 

113.  Jackson 's  tubular  sjieculum   159 

114.  Diagrammatic  representation   of  direct   laryngoscopy ICO 

115.  Position  of  second  assistant  and  patient  for  endoscoi>y  per  os 161 

111).     Bronchoscopy  room  at  Massachu.setts  General  Hospital 102 

117.  Mosher  's  adjustable  speculum    1 63 

118.  llosher's  adjustable  speculum    164 

119.  Forceps  for  direct  work  upon  the  larynx 166 

120.  Killian's  suspension  apparatus    16S 

121.  Mosher 's  folding  frame  for  suspension  apparatus,  closeil 169 

122.  Moslier's  folding  frame  for  susi^nsion  ajiparatus,  open 169 

123.  Urethroscope  used  as  a  tracheoscope 170 

124.  Urethroscope  used  as  a  tracheoscope,  showing  individual   parts 171 

125.  Jackson 's  bronchoscope   1  "3 

1 26.  Jackson  's  bronchoscope,  with  Ijcveled  end 173 

111".     Ca.st  of  the  interior  of   the  trachea  and   bronchi,   with   their  chief   raniitications 

within  the  lung 1 74 

128.     Cast   of   the  interior  of  the   trachea      and   brom-hi.   witli   their   i-hicf    raniitications 

within  the  lung  1 75 

120.     The    arch    of    the    aorta,    with    the    pnlnion;iry    aitery    and    iliief    l.r:in<li    of    the 

aorta    1 76 

130.  Showing  the  relation  of  tlie  trachea  to  the  great  vessels  of  the  neck 177 

131.  Showing  the  divisions  of  the  trachea  and  bronchi 1 7S 

132.  Showing  the  relation  of  the  main  bronchi   to   the  ribs  and   the  chest   wall    (An- 

terior view)    179 

133.  Showing    the    relation    of    the    trachea    ami    main    lininchi    tii    the    chest    wall    and 

ribs   (Posterior  view)    181 

134.  Diagram  to  show  the  brouchoscopic  picture 182 

135.  Diagrammatic  drawing  to  show  the  brcnchoscopic  picture  at  various  levels 183 

J  36.     Horizontal  section  of  thorax  of  man,  aged  57,  at  the  level  of  the  upper  part  of 

the  superior  mediastinum   184 


XX  Il.LrSTi;ATI().\S. 

KIG.  PAGE 

137.  Horizontal   section    uT   tlmriix    of    ni;iii,   a^oil    ."JT,    iiniiu'ili;it('ly    aliovo   the    l)ifun-;i- 

tion  of  the  ti;icln';i 185 

13S.  Horizontal   section    of   the    tlioiax   of   a   man,   a-od    7,7,   at    the   level    of   the   roots 

of  the  lungs ISf. 

VMK  Horizontal  section  of  the  tlioiax  of  a  man,  ased  oT,  at  tlu'  level   of  the  nipples..  1N7 

140.  ■  Biiiuings'  electroscope   ll'l 

141.  Rlieostat  and  battery   1  !i:i 

142.  CooUdge's  cotton  carrier   1!'4 

143.  Ang-ular  forceps  for  use  with  the  adju.stable  speculum 1SI4 

144.  Mosher  's  alligator  forceps    194 

145.  Jackson 's  tube  forceps    195 

146.  Coolidge  's  forceps  195 

147.  Killian's  manikin  for  practicing  bronchosco])y  ami   esophagoscojiy 196 

14S.  Briinings'  elongation  forceps   197 

149.  Tips  for  Briinings '  forceps   197 

150.  Expanding  tip  for  Briinings '  forceps 197 

151.  Mosher 's  spiral  wire  forceps  for  removing  pajiilloma  of  the  larynx 198 

152.  Mosher 's  triangular  fenestrated  tube    198 

153.  Small  bronchoscope  for  emergency  intubation 199 

154.  Pin  with  glass  head  in  left  main  liroiichus - 208 

155.  Casselberry  's  pin  cutter    209 

156.  Section  of  the  human  esophagus  (Moderatel.v  magnified) 211 

157.  Showing  the  relations  of  the  esophagus  from  behind 212 

loS.  View  of  the  stomach  in  situ  after  removal  of  the  liver  and  tlio  intestine 213 

159.  Under  .surface  of  the  diaphragin 214 

160.  Schema  showing  the  range  of  motion  of  the  gastro.scopc 215 

161.  .Jackson 's  esophagoscope   218 

162.  Mosher 's  short  length  oval  e-sophagoscope 219 

163.  Mosher 's   esophagoscope    (short   length) 220 

1 64.  Hood  or  cap  which  protects  the  lamp 220 

165.  Long  conical  plunger  for  Mosher 's  oval  esophagoscope 220 

166.  Window    plug    for    making    the    esopliagoscope    air    tight     and     ballcxming    the 

esophagus    220 

167.  Different  sizes  of  Mosher 's  oval  esopliagoscojies 220 

168.  The   normal    esophagus    above    the    hiatus    of    the    diaphragm,    and    with    the    dia- 

jihragm  contracted    229 

169.  Esophagoscope    pushed    through    the    hiatus    of    the    diajihiagm    and    entering    the 

subphrenic  jiortion  of  the  esophagus 229 

170.  Esophagoscope   carried    through    the    cardiac    opening   of    the    cr.opliag-xis    into    the 

stomach 229 

171.  The  esophagus  just  above  the  hiatus  of  the  diaphragm 229 

172.  Normal  esophagus  during  quiet  breathing 230 

173.  Normal  esophagus  during  deep  respiration 230 

174.  Stricture  of  esophagus  with  scars  radiating  from  its  lumen 230 

175-1 76.     Carcinoma   of   the   esophagus 230 

177.  Fish  bone  in  the  esophagus    230 

178.  Mosher 's  mechanical  dilator  with   two  tips 234 

179.  Modified  Bunt 's  olive-tipped  metal  liougie 2.34 

180.  Stricture  of  the  esophagus 236 

181.  Handle  and  staff  of  Plummer  's  esophageal  whalebone  bougies 2.3» 


U.I.rsTIlATloNy 


FIG. 


PAGE 


1  *2.     Wlmleliono  stnfT  of  Plummor 's  osoiiliajieal  liminic 2:10 

1  s.;.     Mi'tal  stiifT  cariyiiip:  olivp  at  tip ;  spiH'ial  wiio  cani.'r -"^ 

1  S4.     Moslior 's  tw(il)la(le«l  dilator  with  sliOin"-  knifi> 240 

IS.l.     Cardiospasm.     Retouclipd  tracing  from  an  X-ray  plati- 211 

lS(i.     Apparatus  for  ililating  the  oardia 24:'. 

1S7.     Cunliospasm.     Print  of  an  X-ray  platt-  showing  a  .lilatocl  csupliafjiis 24(; 

ISS.     Section  of  normal  csophaf^is   (Low  power') 248 

1  SO.     Carcinoma  of   the  esophagus 2;j0 

1!)0.     Sect  ion  of  carcinomatous  area  (Low  power) 2.-)l 

I'M.     Scctimi  of  carcinomatous  area   (High  jiower) 2.'il! 

1112.     Carcinomatous  stricture  of  the  esophagus 2o2 

Ifi;!.     Cancer  of  the  esophagus.    Rotoueheil  tracing  from  .\'  ray  plate 253 

I'.it.     Korc-cps  with   iiuncli  tiji    255 

l<i.l.     Moslier's   curette    256 

19().     Jack.son  's  foreign  boily  forceps 2(i3 

lit7.     Penny  lodged  in  the  upper  part  of  the  esophagus  of  a  child 2(i4 

19S.      Penny  whistle  ill  the  upper  part  of  the  esophagus  of  a  seven  year  old  child 2(!(; 

\W.     Safety   pin    in   the   esophagus 2fi7 

2nn,     .Tackson 's   forceps   for   grasping   and    pushing   o|)en    safety   i)ins   into   the   stomach 

for  turning    2i;s 

201.  Schema    showing   Jackson's    metlnd    of    removing    an    open    safety    ]iin    from    the 

eso|diagus  by  pa.ssing  it   into  the  stomach 2(i8 

202.  Mosher  's  safety   pin   removing  tulie 2(in 

20."?.     Mosher's  safet.v  pin   forceps    270 

204.     Tooth  plate  in  the  esophagus 270 

L'05.     Jlosher's  instrument  for  cutting  a  tooth  plate  or  largo  pieces  of  luuie 271 

201).     Jackson  's  hronchoscope,  esophagoscopo  and  gastroscope 272 

207.     Position  of  the  right  hand  during  the  introduction  of  the  sastrosc<ipe 274 

208-216.     Historical  illustrations  of  Tagliacozzi  's  work 2S0 

217-222.     Appliances  and  instruments  employed  by  Tagliacoz/i 2S1 

22.'i.     Incisions  and  flaps  for  closing  defects   (Cslsus) 2S4 

224.  Making  Reverdin   graft 285 

225.  Reverdin   graft   applied    2S5 

226.  Making  and  applying  Thiersch   graft 286 

227.  Stereoscopic  photograph  of  plaster  cast 2S7 

228-229.     Legg's    operation    for    correction    of    unilateral    ami     partial    deticicncics    of 

the  nose    291 

2:iO-231.     Koenig's   operation    202 

2.''>2-2.'i;!.     Von   Esmarch  's   operation    202 

2:!4-2.'!5.     Von    Langenbeck  's   operation    202 

2:Mi-2.'!7.     DielTenbach  's  operation    20.1 

2.''.S.     V(m  Esmarch  "s  operation    20.'? 

280.     Busch's  operation  for  partial  loss  of  tip  and  one  side  of  n<ise 204 

240.     Nelaton  's   operation    20.-1 

241-242.     Symc  's  operation    20(i 

24.3-244.     Helfericli's   operation   for   total   loss   of   nose 207 

245-247.     Roberts'  operation  for  sunken  bridge  with   uptimu'il   lobule  or  tip  of  no.se..  200 

248-251.     R<d)erts'  operation  for  sunken  saddle-back  nose .100 

252-253.     Dieflfenbach 's  operation  for  formation  of  new  columella   fmni  the  upper  lip..  302 


XXU  ILIXSTRATIOXS. 

FIG.  PAOi: 

254-255.     Operation    for    fomiiition    (if    lunv    culunu'lla    fi-oni    the    doisum    of    tlic    iioso. 

(Hindoo  method  )    •^^- 

256-260.     T,ox('r"s    o|ioratioii     IHr    tli<'    r(irni;ition    of    coluiiii'll;!    fiiniL    (ho    mucous    mrm- 

liianc    of   till'    ii]i|MT    li{i ^O.i 

261-262.     Italian  or  Tagliaeozzi  's  method -f-1 

26.3.     Italian  or   Tagliaeozzi 's  method •'*"■' 

264-265.     Israel 's    operation    •'"'" 

266-268.     Dieffenliach  's  operation  "'f'^ 

269.     Nelaton  's  operation   •f'^''' 

270-271.     X^laton  's  operation   31(1 

272.     Hindoo  or  Indian  method  of  flap  formation •"■11 

27.').     Thiersch's  operation  for  total  loss  of  nose •'!  1 

274-276.     Nelaton's  operation  f(u-  total  loss  of  nose -il^ 

277-279.     Koenig  's   operation    .315 

280-281.     Keegan's  operation  for  subtotal  loss  of  nose,  in  cases  of  hacked  noses 316 

282-285.     Nelaton's  operation  for  sulitot^l  loss  of  nose -318 

286-287.     Von    Langenbeck's    operation    for    cidlajised     nose;    making    supjiorts,    esjie- 

cially  when  soft  parts  arc  wanting ''l!! 

288-290.     Schiramelbuseh's  operation  for  total  loss  of  nose 320 

291-293.     Schimmelbuseh 's  operation  for  saddle-back  nose 322 

294-297.     Sir  Watson  Cheyne's  operation.      (Indian  method.) 324 

298-300.     Von  Hacker's  operation.     (Indian  uK'thod.  i 32(1 

301-302.     Sedillot's  operation  for  total   loss  of  nose.      (Indian  method.) 327 

303-304.     Steinthal's  operation  for  total  loss  of  nose.     (Double  transplantation  niodiod.)  328 

305-306.     Kausch's  operation   for  collapsed  nose.      (Double  transplantation   method.}..  .329 

307.     Watt 's  operation  for  subtotal  loss  of  nose 331 

308-311.     Wolkowitsch 's  operation  for  total  loss  of  nose.      (Finger  method.) 322 

312.     Von   Esmarch's  operation   for  collapsed   nose  or   absence  of  the   preniaxilla   or   an 

anterior  perforation  of  hard  palate 334 

313-314.     Clavicle  method.      (Gustav   Mandry.) 334 

315.     Israel's  operation  for  saddle-back  nose 33S 

316-319.     Goodale's  operation  for  depressed  nose 339 

.320-321.     Ouston  's  operation  for  depressed  nose  liehnv  the  bridge 340 

322-324.     Carter's  operation  for  saddle-back  nose 341 

325-326.     Carter 's  operation  for  saddle-back  nose .342 

327-328.     Walshou  's  operation  for  collajised   al-.e 344 

329.  Paraffinoma  with  attempted  removal.     Facing  page 350 

330.  Beck's   paraffin   syringe    351 

331-333.     Joseph's    operation    for    redui-iiig    liuni|i,     length,    width    of    nose    and     huge 

nostrils    354 

3.34-335.     Kolle  's  operation  for  humji  nose 355 

336-337.     Beck 's  operation  for   hump   nose 355 

338.  Ballenger  's  operation  for  hump   nose 357 

339.  Ballenger 's  operation  for  long  nose 357 

340-.344.     Roe's    operation    for    humj),    twist    and    broad    ala    or    large    nostiils.       (Illus- 
trated by  Beck.)    358 

345-347.     Roe's  operation  for  broad  aUc  or  l:irge  nostrils.     (Illustrated  by  Beck.)  ....  3(i(l 

348.     Beck  's  operation  for  hump  nose 360 

349-351.     Kolle's  operation  for  long  tip 361 


356 
359 
362 

365 
:«!7 
36!) 

377 

380 

382 

383 

387 

389 

391 

392 

3!"4 

398 

402 

404, 

405 

406 

40 

40S 

409 


ILLISTUATIOXS.  XXIll 

PAGE 

355.     ProtliPtic  or  artificiiil  iiost^s 363 

358.     Goldstein 's  o|>oratioii  for  iK?rf(iniliim  of  m'|iIiiiii 364 

361.     Hazpltiiip's  operation   for   pei-forn(ii>n   of  .scpliini 365 

364.  Usual  operation  for  nmorotia 367 

366.     Parkliill  's  operation   for  niaerotisi 368 

365.  Clievne  ami  Bnrylianl  's  operal  ion   for  niacrot ia 369 

372.     Goldstein  "s   operation    for    macrotiu 370 

376.     Goldstein  's  o]>eration   for  projeclinj;  ear 372 

379.     Beck's  ojieration  for  roll  ear  or  soealled  do<r  ear 372 

381.     SzNTiiaJiowski  's  ojieration  for  reconstnicting  anriele .".74 

Beek  's  operation  for  synechia  of  auricle  to  mastoid 375 

386.     Roberts'  operation  for  absence  of  ear .'>7() 

388.     Simple  operation  for  colobomata .'(77 

390.     Green 's   operation    for    colobomatji .'{77 

Monk 's  operation  for  prominent  ear ."."S 

393.     KoUe 's  operation  for  projectini;  car 37S 

397.     Trautmann  operation  for  closure  of  posterior  deficiencies 380 

401.     The  von  MosetisjMoorholT  operation   for  posterior  deficiencies 381 

403.     Goldstein  's  retro-auricular  jdasl  ic 382 

Celluloid   artificial  ear    382 

Incision  for  spino-facial  anastomosis 384 

Spino-facial  and  peripherospinal  to  descendens  hy|io};lossi  anastomosis 385 

Beek 's  nerve  tracing  forceps 386 

Facial-hypoglossal  end  to  side  anastomosis 388 

Facialhyi>oglossal  end  to  end  anastomosis 389 


\()L.   I. 

OPERATIVH  SI  Rl.liRV  OF  I IIH  NOSH,  TIIROA  l\  AM)  HAK. 


(IIAPTFH  I. 
TIIH  SIKI.ICAI.  AWIOMV  OF   I  III';  NOSH/ 

liv    ilA.X.U      W.    Lul.K,    .M.l,). 

External  Nose. 

Tlip  external  nose  (iiasus)  wliicli  projects  dow nwaril  ami  forward 
from  the  forehead,  between  the  eyes,  presents  two  lateral  and  one 
iiifci-idi-  surface,  all  t I'ian.iiular  in  >liapc,  and  a  siiiiriidr  -urlaci-  which 
vai-Jes  considerably  in  size  and  cniitiiui-.  .\>  mhmi  in  l-"i;;>.  1  and  '2  the 
root  of  the  nose  (radix  nasi)  is  that  portion  i)rojeetinf;-  for  a  sliort 
distance  downward  fT-oni  tlic  forehead,  and  tlic  liridiic  of  the  nose 
(dorsum  nasi)  is  the  superior  ^ui-i'ace  e\lenilin:;-  fnini  the  inot  \n  the 
tip  of  the  nose  (aj)ex  nasi). 

The  supporting;'  framework  of  the  n(i>e  is  c(ini|iosed  of  bones  and 
cartilages,  united  li>  cnunective  tissues.  It  1^  lined  with  mucous  mem- 
brane and  covered  hy  tnuscles  and  inteL':nnient. 

The  nasal  bones  ami  the  frontal  |iro<'esses  (pi-ocessus  frontales 
nia\ilhc)  of  the  inaxilhc  which  constitute  the  hoiiy  framework  of  tlie 
external  no>e  are  attached  hy  -iron.n  i-onni'cti\e  ti>,-ne  fiher-  to  the 
lateral  cartilages  (cartilaiiines  nasi  lateiales)  at  the  apertura  ]iiri- 
formis  (Fif^s.  1,  2,  9  a)id  11).  Kach  of  these  cartilasos  is  triangular  in 
shape  with  the  apex  downwaiil,  and  is  attached  to  the  cartilage  of 
the  .septum   (cartilago  septi   nasi),   ami    to   its   fellow    on    the    oppo- 

*For  the  convenience  of  readers,  structures  arc  designated  by  their  usual  English  names.  However, 
the  B.N. A.  nomenclature  is  given  in  the  text  and  exclusively  in  the  figures  in  order  to  follow  recogniied 
authority  in  terminolog>'. 

The  figures  .iccompanying  this  chai)ter  have  been  made  from  drawings  of  Mr.  Tom  Jones,  with  the 
exception  of  Figs.  20  to  3A,  inclusive.  Acknowledgment  is  gratefully  made  to  Or.  D.  M.  Schoemaker  for 
the  dissections  illustrated  by  Figs.  1,  2  and  3.  The  remaining  preparations,  except  those  illustrated  by 
Figs.  9,  II  and  12,  were  made  by  the  author. 


Ol'EllATlVli   Sl'RGERY   OF   THE   NOSE,   THROAT,   AND   EAR. 


DIX     NASI 


PROCESSUS 


OS     NASAl_E 


/'V 


Fig.  2. 
The  cartilages  of  tlie  nose;  anterior  view. 


TlIK    sniCICAl.    ANATOMY    HI'    ■|IIK    XnSl'.. 


sill'  >\t\v.  A  \;iri;ililc  iiiiiiilii'i-  of  si-^niiKtiil  cjtrl  il;i,L;i'>  ( i';irtil;i'_:iiH'S 
sesaiuiiiilca')  ai'c  round  lirt  \\  ecu  \\\r  latci'al  iia>al  cartilaui-  ami  llif 
.U'l'calci'  alar  i-aiiila.L;i'  ( i-ai'lila^n  alari-  iiiajoi').  The  N'.-mt  alai'  car- 
tila,i;c's  I  carlila^incs  alans  niiimrrs)  ;!i'i'  small  c-ail  il,-iL;imius  jilaU'S. 
\arialili'  in  iiumluT,  wliirli  Iji'  liclwi'mi  llic  i;rcnliT  alar  carlilavt'  aii<l 
llic  maxilla. 

Tlie  ii'ivatt'i-  alar  i-aiiilanv   ( I'ai-tila'^n  alaris  major).  \frv  varinl)li> 
in   sliape  and   cxtcal,  coiisl  ituli's   in    lai-.L^c   nifasurc   tlic   I'lamcwovk  of 

till'    lower    lateral    poiti f    tlir   i^xlcnial    nosr.    and    Uial    of    llic    ala 

(cnis  lalcralc).  T\\r  niiMlial  portion  (c-rns  mcdialc)  li-'ii;-.  .".)  \vi)ids 
around  the  antcfior  infciioi-  poitioii  uixini:'  to  tlie  nari-  its  roundi-d 
appearance.  It  is  loosely  conneeted  with  tlie  carlila.ue  of  llie  .<e]jluni. 
A  mass  of  connective  tissues  lies  lieliiml  and  lielnw  the  greater  alar 
cartila,;;-!^  formiui;-  a  consideralile  jioi-tion  of  tlic>  ala   (tela  snlicntanoa). 


CRUS     MEDIALE 


The  orifices  of  the  no.se  sliouiii; 
the  cartilagines  alaies  niajoros. 


(lissortioii  (if  the  cniia   iiu'dialia  of 


Nasal  Cavities. 

Tlie  anlei-i(i|-  |iorlion  oT  tlie  nasal  cavities,  lietwceii  tlic  .-da  and  Ilie 
septum,  is  called  (lie  \cslilinle  (  l''i.i;s.  '.].  (i  ami  7).  it  i>  coxcred  with 
squamous  ei)itlielium  and  contains  numei'oiis  stiff  liairs  known  as 
vil)rissa\ 

1'lie  nasal  ca\-ities.  rii^ht  and  left,  are  liollow  spaces  ttetweeii  tlie 
liones  of  tile  head  and  face,  extemlinu'  hackwaid  fidin  the  vestilinle  (o 
the  naso])haryn\,  and  from  the  IIimh-  of  tli<'  cranial  ca\ity  aliove  to  the 
I'oof  of  the  mouth  lielow. 

Floor  of  the  Nose.  The  Imuix  lloor.  narrowest  at  its  anlciaor 
extremity,  hecoiniui;-  wider  po-leriorl\  and  tlnMi  narrower  at  tlie 
choana?,  is  formed  iiy  the  palatal  |ii-oces>  of  the  maxilla  ('])rocessus 
palatinus  ossis  mavijlaris)  and  the  pal.alal  pioce^,^  i,|'  the  palate  l)0lie 
(processus  ]ioi-i/,ontali>  o>si-  p.alatini).  The  .-iilure  helweeii  these 
hones  divides  the  lloor  into  two  niMMpial  portions,  the  anterior  three- 
foiirtlis   ap])roxiiiiately    heint;    maxilla    and     the     po-leiior     oneTourth 


4  (i|'i:i:aii\  K  sritcKiiv  of   thk  xosk,  ■riii'.nAi',  axu  kai;. 

palate  lioiic  (  Fi.i;'.  4.)  'I'hc  caii.-ilis  inci.-ivus  which  (jjioiis  (ni  tlio 
septum  .jii.-t  alioxt'.  ju'iicfralcs  Ihc  lldor  in  its  aiitci'ior  iiorlion  coiivcy- 
iiip'  till'  iiasoiiahitinc  ihma'c  ami  arli'iy  lo  llic  rooT  of  llic  mouth.  Tiie 
sinus  inaxillaris  may  1»(^  seen  I'xtcnial  to  the  latci'al  wall  of  the  nose 
oxlcudiui;-  liclow   llic  level  of  the  lloor.      (See  also  l-'if;-.   1?,.) 

Septum  Nasi.  -The  sejitum  nasi  tornis  the  inner  wall  of  each  nasal 
cavity,  ai)proximately  in  tlie  median  line,  it  may  be  .'^tvais'ht,  but 
more  often  it  is  ])ont  to  one  side  or  the  other  or  irre^'ularly  deviated 
in  one  or  both  nares.  It  is  divided  into  three  ]iar(s,  tlie  bony  (se)iluni 
nasi  oss(Mim).  cartilaginous   (cartilagineum)   and  membranous    (mem- 


OR1ZONTALIS 


'//  "'"'' 


CANALIS    INCISIVUS 


SPINA     NASALIS     ANTERIOR 


Fig.   4. 
Floor  of  tlie  nose. 


l)ranaceum)  septum  (F\p;.  5).  Tlie  memliranoir-  jiortion  (septum  mobile 
nasi)  separates  the  vestibule  from  its  fellow,  and  is  made  up  of  tlie 
crura  medial ia  of  the  two  greater  alar  cartilages,  Avith  tlieir  attach- 
ments to  the  septum  nasi,  covered  by  a  mucocutaneous  investment.  The 
cartilaginous  portion  (septum  cartilagineum)  is  formed  by  tlie  car- 
tilage of  the  septum  and  the  cartilage  of  .Tacobson.  The  cartilage 
of  the  septum  is  more  or  less  qiiadrilateral  in  form  and  is  attached 
posterosuperioi-ly  to  the  perpendicular  jilale  of  tiie  ethmoid  (lamina 
perpendiciilaris  ossis  ethmoidalis),  ]iost<'roinferiorly  to  the  groove  of 
the  vomer,  inferiorly  to  the  anterior  ])art  of  the  crista  nasalis  maxillfe 
and  to  Jacobson's  cartilage,  and  superiorly  to  the  nasal  bones  and  tlie 
lateral  cartilages.  From  the  posterior  angle  a  projection  extends  back- 
ward often  for  some  distance,  known  as  the  processus  sphenoidalis 
septi     cai-tilaginei.      Jacobson's    cartilage     (cartilage    vomeronasalis 


Till",    SflMMCAI,    AXATOMV    (H      IIIK    XOSIC.  0 

.laculisuiii)  lies  Ix'lwet'ii  lla-  cartila;;i'  ami  the  voiir'I-,  ;iik1  Hjc  nasal 
crest  ol'  the  maxilla. 

Till'  l)oiiy  ])(ir(io7i  is  eoniposed  (if  tlie  periu'iidicular  ])lat(>  of  llie 
ctliiiiniil.  lln'  in>liuiii  1)1'  tile  s|iliciii)it I  (crista  s]ilieii()i(lalis),  the  vomer, 
llie  maxillary  crest  (crista  iia.-alis  niaxilhc),  ami  flic  iialaliiic  crest 
(crista  iiasalis  ossis  ])alatiiii). 

The  ])er])eii(licular  phitc  of  the  ethmoid  extemls  downward  and 
I'oiwaiil  from  the  criiiiiloriii  ]ihile  ol'  the  ethmoid  (lamina  crihrosa  ossis 


LAMINA 

PERPENDlCUl 

LAMINA                           _ 

CRIBROSA             ^^ 

CRISTA                                              ^^^H 

SPHENOIDALIS                           ^^^^S 

SINUS 

jtf^^^^B^^I 

SPHENOIDAL! 

'    '     1         "iJM^B 

OS     FRONTALE 


v 


-^^ 


>S     NASALE 

•••nTILACO      NASI 
LATERALIS 

-RTILAOO 
LPTI    NASI 

CARTILAOO 
ALARIS     MAJOR 

>^ 

CARTILAGO 

VOMERONASALIS 

(JACOBSONIt 


Fig.  5. 

Tlie  si'iitmii  nasi. 


■ethmoidalis)  liavinp;  attachmeni-  with  (lie  nasal  spine  (spina  iiasalis) 
of  the  frontal,  tlie  nasal  bones,  llie  cartilafres  of  the  septum,  the  vomer 
and  (lie  lostrum  of  the  splienoid. 

The  vomer  constitutes  ])racl  icallv  llie  wlmle  nf  the  |M)>(ei-ior  ami 
inferior  ])art  of  the  sej)tiim,  articiilatini^  helow  with  the  nasal  crest 
of  tlie  maxillary  and  palate  l)ones.  anteriorly  and  superiorly  with  the 
cartilaf,^e  of  the  sc|ituiii.  .lacuhson's  carlilaye  and  the  pei-pendicular 
I)late  of  the  ethiiKiid,  ami  suiii'rioilv  with  the  rostrum  and  hodv  of  the 


b  (il'KKATIVK    sriKiKKV    (iK    Tl  I  K    MISK.    'niKoA-l'.    AND    KAi;. 

spliciioiil.      Its   sii|irri()i'   in;ii-.i;iii   d'niih's    into   two    wiim's,   al;i'   \'(jiii('ris,, 

liy  w  liicli  it  is  attnclicd  to  the  sphenoid.     The  jiostcrior  liordcr  t'oniis 

the  di\idin,u'  lioumlary  of  tlic  two  clioaiia'  (if  iiostcrioi'  iiarcs.     (I^'i.i;'.  8.) 

'I'lic   nislriiiii  of  the  sjiliciioid   lakes   part    in  the  Torniation   ol"  tho- 

SINUS      FRONTALIS 

'     AGGER      NASI 


MEATUS      NASI      INFERIOR 

Fig.   6. 
T'hi'  (lutcr  wall  of  the  risht   iias:il  oavitv 


septum.    In  the  specimen  illustrated  (Fiii'.  ."))  it  is  trianf;iilai-  and  eon- 
sideral)ly  larger  than  u.=;uaL 

The  maxilla'  furnislies  hut  a  small  part  of  the  nasal  septum,  the 
crista  nasalis,  whicli  by  its  articulation  witli  the  vomer,  Jacobson's 
cartilage,  and  tlie  cartilage  of  tlie  septum,  comprises  the  inferior  por- 
tion of  the  septum,  corresponding  to  tlie  extent  of  tlie  maxillary  portion 
of  the  floor.  In  its  anterior  half  it  presents  the  eanalis  incisivus  for  the 
passage  of  the  nasopalatine  nerve  and  artery.     Its  most  anterior  pro- 


liii:  srucTfAT.  AXATfnrv  oi-  -I'liK  xnsK.  I 

.■jection  is  tlic  Miili'iior  ii;i>;il  -|iiiii'  (-pliKi  ii,-i>;ili>  nnji'rinr) .  (I-'Ili's.  4 
and  ').) 

Corrospoiidiim'  wifli   I  lie  luisal  crc-t   of  lln'  nin\illai"y  is  a  similar 

pro  jection  n]nvanl    i'ioim   Hie  lioi'ix.onlal   jilale   nf  the   ])alalo  ))()iic.      If 

lie>  lieliiiiil  the  iia-al  (•i'e>|  ,)\'  tile  iiia\illai-\-  ami  art  iriil;,tes  willi  i)  at 
the  >utui'a  jialaliiia  tran.-\-ei-.-a.  I'd-leiinily  it  |ire>ents  the  pn^lci-iiir 
s])iiie  (spina  nasalis  juistcrior). 

Roof  of  the  Nose.       'i'he   roof  df  Ihe   mi>e   is  constituted    iVoMI    herciiv 

liacl<\vai-d  l.y  tlie  rollowiii-  hoiie>:  the  ii;i>al,  tli.'  frontal,  the  ethmoid 
and  sjilicnoid.  The  lamina  crilno^a  of  the  ethmoid  (  l''ij;-s.  5,  12,  4."),  4(1. 
4S,  .lO,  ')'.],  7)4  and  o.") )  w  hich  cnii\ey>  the  lilam<'n(-  of  the  olfactory  novvo 
(Fi.iis.  44  and  47 )  I'rom  the  ci'aiiial  ca\  il>  info  t  he  nasal  cavity  is  almost 
horizontal.  If  is  cumpo.-ed  i>\'  \ciy  hartl  lioni'  which  is  easily  vooo.c;- 
nized  liy  the  operafm-  on  aeeonnf  of  it>  resistance  fo  the  in^f  runiont. 
The  si)]u'noi<l  oi'dinarilx'  constitutes  hut  a  small  ]iart  of  tlie  voof  of 
the  nose  just  hehind  the  ethmoid,  like\\i.-e  the  frontal  whicli  lies  .-just 
antorior  to  the  eflinmid.     .\nterior  \n  the  sphenoid  in  the  anuh>  luMAveon 

it   and   the  ellinioid.   tllere   is  a   >pace   culled    the    recessns   ^|i]|eUoef  hmoid- 

alis,  which  recei\es  the  openiii,i;'  of  the  sjihenoid  sinus. 

A  prolie  with  its  end  ti|)])od  slightly  downwaid  will  reaiiily  enter 
th.e  sjilienoid  if  it  is  passed  ha(4<wari|  aUnut  7  cm.  alone'  the  roof  to 
flip  recessns  spheiioefhmoidali^.  .\,-  a  I'ule  to  accom])lisli  this,  it  is 
necessary  to  resect  the  middle  turhinate.  Fig's,  fi  and  7  show  very 
ch'arl\'  tin'  ^lossihility  of  nsiui;-  this  nii'thoil. 

External  Wall  of  the  Nose.— The  maxilla  and  j.alate  whicli  are 
united  verticallx',  with  tlieir  attachments,  the  infeiioi-  turhinate  (con- 
cha nasali>  infeiior),  lacrimal.  I'fhmoid  and  sphenoid,  eonsfitule  the 
outer  wall  of  the  nose.  The  inferior  furhimili'  and  the  middle  tur- 
binate (concha  nasalis  media)  ( Fiizs.  (i,  7,  l-'i.  Hi.  17  ami  IS)  are 
attached  to  the  crista  I'onchali^  ami  ci-ista  furhinalis  of  the 
maxilla  and  of  the  iialafi'  hone.  The  >u|ierior  tnihinate  (concha 
nasalis  snpei'ior)  an<l  supreme  tui-liinate  (concha  nasalis  -uju'ema). 
which  is  ])i-eseiit  in  ahout  onefhii-il  of  the  cases,  run  jiarallel  to  the 
mi<Idle  tui'hinafe.  hut  ui-e  coiitinuou.-  with  the  lateral  ma^'^  of  the 
ethmoid  from  wi,icli  Hie\  project  h.-n-kwai'd  foi-  a  >horf  di>tance.  The 
infei'im-  turhinate  and  middle  turliinafe  extend  ahout  the  same  dis- 
tances forward,  constifnf  Iiil;  Ii\  far  the  uiealei-  portion  of  the  pro.jeclion 
from  the  external  wall.  .\  line  diawn  idonu  Hie  su])erior  border  of  llie 
middle  turhinate  and  exP^ideil  lo  (he  nnterior  wall  di\ides  the  nose 
into  two  uueipml  part>.  ;i  .-uperior  compri-iim'  about  oiie-liffh  and  an 
inferior  about  fourdiffhs.  'V]\v  superior  and  su|u-eme  turbinates  are 
much  sniidler  and  shorter  than  the  other  turbinates.    Tiiey  sjnin.u:  from 


8  OPERATIVE   SURGERY   OF   THE   NOSE,   THROAT,   AXD   EAR. 

t]ie  lateral  mass  of  the  ethmoid  in  tlie  posterior  third  of  the  nasal  wall. 
However,  all  of  the  turbinates  extend  about  the  same  distance  backward. 
The  choanje  therefore  are  in  relation  with  the  posterior  ends  of  the 
inferior  and  middle  turbinates.  (See  Fig.  8.)  The  superior  and 
supreme  turl)inate  lie  just  above  the  superior  choanal  level.  Upon 
examination  through  the  anterior  nares,  the  inferior  is  visible  for  from 
one-lialf  to  its  Avhole  length,  tlie  middle  ordinarily  at  its  anterior  end, 


ilNUS      FRONTALi! 


NASALIS      SUPERtO 
RECESSUS    SPHENOETHMOIDALIS  ', 

^PeRTURA      SINUS     SPHENOtOALIS 

SINUS     SPHENOIDALIS 


CONCHA      NASALIS      MEDIA 


SALIS     INFERIOR 


The  outer  wall  iif  tlio  left  nasal  cavitv  with  the  oinu'ha  lue.lia  removed. 


and  the  superior  and  su))iem('  are  not  visible  unless  extensive  atrophy 
is  present  or  unless  the  middle  lurbinate  has  been  removed. 

The  inferior  turbinate  is  attached  to  the  lacrimal,  constituting  a 
portion  of  the  M-all  of  the  nasolaci'inial  canal,  and. to  the  ethmoid;  it 
serves  to  decrease  the  size  of  tlie  oi'ifice  of  the  maxillary  sinus. 

The  turbinates  are  covered  with  nmcous  membrane,  continuous 
with  tlio  mucous  memlivaite  of  the  external  wall   of  the  nose.     It  is 


THE   SURGICAL   AXATOMY   OF   THE    NOSE.  J 

liiickest  over  the  infevior  and  niitldlc  turbinates,  made  so  by  the  large 
number  of  venous  radicals  Avhicli  aie  present.  These  have  been  vari- 
ously designated  as  turbinate  bodies,  Sclnvellkorper  (by  Znekerkandl) 
(plexus  cavernosi  concharum) ;  they  are  of  great  importance  in  the 

APERTURA      SINUS    SPHENOIDAUIS 


OCULOMOTORIUS 


=tS     H0RI20NTAL1S 


The  choauffi  ami  anteriur  wall  of  the  siiheiioid  sinus  vicwea  from  liehiiul. 


physiologic  action  of  the  nose,  more  particularly  in  connection  Avith 
respiration. 

There  is  a  small  elevation  on  the  outer  Avail  just  anterior  to  the 
middle  turljinate  knoAvn  as  the  agger  nasi.  It  is  sometimes  the  seat  of 
an  anterior  ethmoid  cell.  Tt  is  by  entering  through  the  outer  wall  at 
the  agger  nasi  that  Moslier  reconnnends  that  the  ethmoid  cells  be 
curetted  Avithout  distui-l)ing  or  necessarilv  removing  the  middle  tur- 


10  OPEKATIVE   SURGERY   OF   THE   XOSE,   THROAT,   AXD   EAR. 

biiiate  lione.  Below  lliis  is  a  s]if;'lit  dopression  kiioAvn  as  atrium  meatus 
medii,  which  exteuds  l)ac'kwaTd  aud  downward  into  the  iiiiddh>  meatus. 

By  virtue  of  tlie  turbinate  ledges  on  the  external  wall,  the  nasal 
cavity  is  divided  into  three  meatuses,  the  inferior,  middle  and 
superior  (Figs.  6,  13,  17  and  18). 

The  inferior  meatus,  below  and  lateral  to  the  inferior  turbinate 
bone,  receives  the  lacrimal  secretion  through  the  orifice  of  the  naso- 
lacrimal duct,  in  its  anterosuperior  poi'tion.  None  of  the  accessory 
sinuses  opens  into  it. 

The  middle  Tueatus  contains  the  orifices  of  the  frontal  and  max- 
illary  sinuses,  and  of  the  anterior  ethmoid  cells.  These  orifices  in 
the  main  open  into  the  infundibulum,  a  liollowed  out  space  below  tlio 
maxillary  attachment  of  the  middle  turbinate  and  between  the  bulla 
ethmoidalis  and  the  uncinate  process  of  the  ethmoid  bone  (Figs.  7  and 
13).  The  frontal  and  one  or  more  of  the  anterior  ethmoidal  cells  open 
usually  through  its  anterior  and  upper  portion. 

The  maxillary  sinus  op(^ns  as  a  rule  posterior  to  the  orifice  of  the 
frontal  sinus.  It  not  infr(>quently  lies  in  such  a  position  that  discharge 
from  the  frontal  and  ethmoid  cells  passes  directly  throiigh  the  in- 
fundibulum into  the  maxillary  sinus.  The  opening  of  the  maxillaiy 
is  not  ah\ays  single;  one  or  more*  accessory  orifices  may  be  present, 
but  they  ojien  into  the  middle  meatus.  The  infundiliulum  communi- 
cates Avitli  the  middle  meatus  through  the  hiatus  semilunaris. 

The  superior  meatus  contains  the  openings  of  most  of  the  posterior 
ethmoid  cells.  Occasionally  one  is  found  above  the  superior  turbinate. 
Behind  and  above  this  is  the  opening  of  the  sphenoid  in  the  spheno- 
ethmoidal recess. 

The  Choanse  or  posterior  nares  which  are  the  openings  of  the 
nose  into  the  nasojiharynx  are  oval  shaped  and  fairly  synnnetrical. 
They  are  foi'med  by  the  vomer  internally,  the  horizontal  plate  of  the 
l)alate  inferiorly,  the  vomer  and  s])henoid  superioi'ly,  aud  externally 
by  the  processus  pterygoideus. 

Fig.  8  is  an  illustration  of  the  choana^  from  lKd]ind  with  the  infe- 
rior portion  of  the  anterior  wall  of  the  sphenoid  sinus  cut  aAvay  so 
as  to  show  the  nasal  cavity  projecting  al)ove  the  upper  level  of  the 
choanje.  It  also  serves  to  show  the  relation  of  the  sphenoid  sinuses 
to  the  choanal',  the  nasal  cavities,  and  the  optic  nerve. 

Posterior  to  the  choana-  on  each  lateral  Avail  of  the  ])harynx  is 
the  opening  of  the  Eustachian  tube.  Tn  children  the  nasal  cavities 
are  relatively  smaller  than  in  adults  for  the  reason  that  the  turlnnates 
are  far  larger  in  proportion. 


THE    SrnciCAL    AXATll.MY    OF    TIIK    XOSK. 


11 


Accessory  Sinuses  of  the  Nose. 

The  accessory  sinuses  of  llie  ikisc  are  eavilirs  in  llie  itiaxilhxry. 
frontah  etlimoid  and  siiliciioid  Ixnics.  wliieli  ai'c  liinnl  with  a  iinieosa 
conthuious  -witli  tliat  oT  tlic  nose;  lliey  conununieatc^  Aviili  the  nasal 
cavities  in  ])hrces  more  or  h>ss  (h^finite. 

In  order  to  understand  llicir  different  rehrtions.  it  is  advisable  to 
stnclv  the  hones  -which  form  their  walls. 


OS  FRONTALE 

SUtURA  INTERNASALIS 


FORAMEM      OP 


PERTURA      PIRIFORMIS 


CRISTA      LACRIMAL 
POSTERIOR 

FORAMEN 
INFRAORBITALS 


;         SULCUS      INFRAORBITALIS 
SINUS     SPHENOIDALIS 
CELLULA       ETHMOIDALIS      POSTERIOR 


Fi,-.    1'. 

The  left   oihit:   Ijone   relations. 


The  two  nasal  hones  united  at  the  sutura  iuternasalis  and  the 
two  maxillary  bones  united  at  the  sutura  intermaxillaris,  to,a,'ether 
with  the  corresponding  nasal  bones  at  the  sutura  nasomaxillaris  form 
the  apertura  piriformis,  or  the  entrance  to  the  bony  nose  to  which  the 
soft  parts  of  the  external  nose  are  attached  (Figs.  9  and  11).  The  nasal 
bones  above  form  the  ])ortion  of  the  roof  of  the  nose  which  lies  anterior 


12  OPERATIVE   SUEGEEY   OF   THE   KOSE,   THROAT,   AJvD   EAR. 

to  the  frontal  Avitli  Avliicli  tliey  articulate  at  tlie  nasofrontal  suture. 
Tlie  maxilla  constitutes  the  anterior,  external  and  posterior  Avails  of 
the  sinus  maxillaris  Avhicli  it  encloses.  It  articulates  externally  Avith 
the  malar  (os  zygomaticmn)  at  the  sutura  zygomaticomaxillaiis.  It 
is  extended  into  the  orbit  and  assists  in  forming  its  floor  by  articulating 
Avith  the  lacrimal,  ethmoid  and  sphenoid  bones.    In  the  orbit,  as  shoAA'n 

SINUS      FRONTALIS 


{ 


/ 


-.ERVUS     OPTICUS 


SINUS      SPHENOIDALIS 


OS      ZYCOMATICUM 
SINUS    MAXILLARIS 

Fii;.  10. 
Left  orbit  with  bone  lemovod  exposing  tlie  mucosa  of  tlie  accessory  sinuses. 

in  Fig.  9,  the  sinuses  are  Aisilde  where  the  bone  has  been  cut  aAvay, 
the  ethmoid  in  the  lacrimal  and  ethmoid  bones,  the  frontal  in  the 
frontal  bone,  and  the  siDhcnoid  in  the  sphenoid  bone.  A  realistic  A'ieAV 
of  the  sinuses  is  seen  in  Fig.  10,  in  Avhicli  the  decalcified  bone  in  the 
specimen  illustrated  has  been  remoA'ed  leaAdng  the  mucosa  of  the 
sinuses  intact,  the  frontal,  anterior  and  posterior  ethmoid  and  the 
sphenoid,  from  before  bachwavd,  and  the  maxillary  beloAv.    From  these 


THE   SURGICAL   AXATOMY   OF    THE    XOSE. 


13 


ligures  it  is  easy  to  ol)servo  liow  an  iiifhuninaiioii  oi'  the  otlnuoid  cells 
may  result  in  a  iieriorbital  abscess. 

In  Fig.  11,  the  outer  plate  and  cancellous  tissue  over  the  frontal 
sinuses  have  been  cut  away  leaving  the  sinuses  free  with  a  thin  cover- 
ing of  bone.  The  sinuses  are  somewhat  larger  than  the  average,  but 
their  relation  to  the  adjacent  bone  structure  is  well  shown. 


OS     NASALE 


;INUS      FRONTALIS 


^EN      SUPRAOR 


PIRIFORMIS 

OSSEUM      ANTERIOR     CONCHA      NASALIS     INFERIOR 

Fiy.  11. 
Bones  of  the  nose  luid   orbits;   external  pkite  over  frontal  sinuses  removed. 

The  roof  of  the  nose  and  of  the  orl)its  from  the  endoeraiiial  side 
is  presented  in  Fig.  12.  The  relations  of  sinuses  to  the  lesser  wing 
of  the  sphenoid  bone,  the  pituitary  fossa  (fossa  hypophyseos),  the  optic 
chiasm,  the  frontal,  and  the  cribriform  plate  of  the  ethmoid  bone  are 
shown.  The  frontal  sinuses,  anterior  and  posterior  ethmoid  cells  and 
sphenoid  sinuses  are  shown  in  succession. 


14 


OPEKATIVE   SUKGERY   OF   THE   XOSE,   THROAT,   AND   EAR. 


A  clearer  understanding'  of  tlie  cells  from  this  aspect  may  be 
secured  from  Fig.  52,  Avliicli  is  made  from  a  specimen  which  Avas  pre- 
pared after  decalcification  by  removing  the  endocranial  bone  covering 
from  the  sinuses,  leaving  the  mucosa  intact.  The  relation  of  the  optic 
nerve  to  the  two  sphenoid  sinuses  and  to  the  last  posterior  ethmoid 
cell  is  Avell  brought  out  in  this  illustration. 

Frontal  Sinus. — The  frontal  sinus  is  the  most  anteriorly  placed  of 


-RISTA     GA 


FORAMEN     C/eCU^ 


SINUS      FRONTALIS 


SINUS      FRONTALIS 


PROCESSL  ' 
CLINOIDEU 
ANTERIOR 


SINUS    SPHENOIDALIS 


FOSSA       HVPOPHVSEOS 


Fig.  12. 
Floor  of  tlie  niitcrior  craiiial  fossa;   lioiiy  roof  of  accessory  sinus  removcil  in  part. 


all  the  accessory  sinuses  of  tiie  nose.  It  varies  greatly  in  size,  but 
conforms  in  some  measure  to  a  uniform  plan  in  that  the  size  laterally 
depends  upon  how  many  recesses  more  or  less  resembling  one  another 
are  present.  Thus  tlici'e  may  W  one,  two,  three  or  even  four  of  these 
recesses  present.  The  frontal  sinus  lies  between  the  two  plates  of  the 
frontal  bone.    Its  ant(nior  wall  forms  the  prominence  of  the  forehead 


THE    SURGU'AI,    AXATO.MV    OF    THE    XOSE. 


15 


al)Ove  tlio  eyolirows.  (Sec  Fi.i;-.  11.)  'I'ln'  ])ost(.'rior  and  superior  wall 
separates  it  from  the  frontal  loi)c  of  the  ))i-aiii,  the  inferior  from  the 
orbit.  The  irre,i;ularities  in  the  anterior  wall  are  well  shoA\n  in  tliis 
figure,  as  well  as  the  relation  in  the  oi'hil   and  the  foramen  supraor- 


CR'STA     GALLI 


JS      FRONTALIS 


CELLULA 
STHMOIDALIS 
ANTERIOR 


CONCHA 

NASALIS 

MEDIA 


Fig.  l.l. 
Coronal  soption  tlirouLili   tlie  nose  ami  mliit. 


Iiitale.     Ea(liof;ra])hs  sliow  the  extent  and  sliape  of  this  Avail  and  are 

therefore  required  before  radii-al  o])('rative  ]n'oeedures  are  undertaken. 

Tlie  relation  of  tlie  ])osterior  and   suiicrim-  wall  to  the  brain  has 

been  studied  extensively  1)V  Onodi,   who  found   (hat   this  wall  of  the 


16  OPERATIVE   SURGERY   OF   THE   XOSE,   THROAT,   AND   EAR. 

frontal  sinus  may  extend  over  tlie  gyrus  frontalis  superior,  gyrus 
frontalis  medius  and  gyrus  frontalis  inferior.  Tlie  inferior  Avail  is  in 
relation  Avith  the  orbit  (Fig.  13)  and  reaches  often  far  back  into  the 
ethmoid  labyrinth.  As  a  rule  it  extends  but  a  short  distance  pos- 
teriorly over  the  orbit  Avhile  laterally  it  is  usually  limited  to  the  inner 
and  middle  thirds,  although  in  some  instances  it  may  reach  the  outer 
third.  The  septum  between  the  two  frontals  is  seldom  directly  in  the 
median  line,  on  Avhich  account  either  sinus  may  extend  beyond  it. 
The  cavity  is  often  subdivided  by  more  or  less  complete  septa  Avhich 
have  the  effect  of  establishing  pockets  in  Avhat  Avould  be  otherAvise  a 
smooth  caAdty.  Fig.  11  shoAvs  hovr  irregular  it  may  be.  The  sinus 
opens  into  the  middle  meatus  by  Avay  of  the  infundibulum  through 
an  elongated  canal  (Figs.  7,  15,  16,  17  and  IS)  or  simply  as  a  foramen 
directly  into  the  infundibuhnn.  A  A^ery  characteristic  formation  of  the 
uiDper  portion  of  the  infundiltulum  is  shoAvn  in  Figs.  15  and  16,  in  Avhicli 
it  lies  behind  an  anterior  ethmoidal  cell,  quite  similar  in  appearance. 
In  Fig.  16,  the  frontal  is  seen  opening  into  the  infundiliulum  through 
a  canal.  Theie  has  been  considerable  confusion  in  the  application  of 
the  terms  infundibulum  and  hiatus  semilunaris.  Onodi  includes  under 
the  term  hiatus  semilunaris,  the  entire  space  betAveen  the  uncinate 
process  and  the  b\illa  ethmoidalis  of  the  ethmoid  bone,  and  accepts  the 
designation  of  Killian,  recessus  frontalis,  for  the  sharply  outlined  fossa 
into  Avhich  the  frontal  often  opens.  "\^'liere  a  canal  is  present,  he  terms 
it  ductus  nasofrontalis.  It  is  quite  conmion  for  one  or  more  ethmoid 
cells  to  open  Avith  the  frontal  through  the  infundilndum,  furthermore  the 
orifice  of  the  maxillary  sinus  may  lie  in  sucli  a  position  that  it  receiA'es 
the  pus  Avliich  floAvs  from  the  frontal  sinus  and  ethmoid  cells,  giAdng 
the  impression  that  suppuration  of  the  maxillary  siniis  is  present. 

Maxillary  Sinus. — The  maxillary  sinus  as  Avill  be  seen  in  Fig.  14, 
is  a  cavity  in  the  maxilla  interposed  between  the  alveolar  process  and 
tlie  OTbit  and  the  external  Avail  of  the  nose  and  the  malar_process.  A 
portion  of  the  anterior  Avalt  has  been  cut  aAvay  bringing  Tlie  cavity  into 
view.  That  portion  of  the  alveolar  process  coA^ering  the  roots  of  the 
teeth  has  been  cut  aAvay,  to  shoAv  their  relation  to  the  floor  of  the 
sinus.  In  the  specimen  illustrated  the  roots  of  the  three  molars  and 
tAvo  bicuspids  are  in  close  relation  Avitli  the  sinus,  Iavo  of  the  roots  of 
the  second  molar  making  imlcntations  into  the  floor.  The  cuspid  lies 
anterior  to  the  sinus,  Init  it  oxtonds  above  the  floor. 

The  floor  of  the  sinus  is  by  no  means  smooth  or  regular;  as  a  rule 
there  are  bony  septa  present  A\hicli  divide  it  into  pockets.  Hence 
puncture  through  the  alveolus  Avill  not  necessarily  result  in  satis- 
factory drainage.  The  floor  of  the  nose  is  generally  on  a  higher  level 
than  tliat  of  the  sinus.     (See  Figs.  4  and  1.3). 


THE   StTRGTCAL   A^\\TOMY   OF   THE    NOSE. 


17 


Tlie  postevior  limit  of  llie  maxilla  scparalcs  llio  maxillary  sinus 
from  the  zygomatic  fossa  (fossa  iiil'ra(('iii]ioralis).  Tlio  lloor  of  llio 
orbit  in  part  constitutes  the  roof  of  the  sinus  and  the  extei'nal  Avail 
of  the  nose,  its  internal  wall.  The  cana!  for  the  infraorbital  nerve 
forms  in  most  instances  a  ridge  on  the  roof  of  the  sinus;  however,  tiie 
ridge  may  not  be  Avell  marked  and  may  he  even  absent.     (Fig.  13.) 

Tlie  opening  of  the  sinus  into  the  middle  meatus  is  on  the  internal 
wall,  generally  in  its  upper  part ;  at  times  there  are  accessory  openings. 


ZYGOMATI  CO  FRONTALIS 


OS  ZYGOMATICUM      / 


Higlit  lateral  view  of  l)oncs  (if  tin 
of  the  teeth  exposed. 


14. 

!  fac 


witlL  iiiaxilhirv  sinus  and  roots 


Hence  it  is  that  pus  in  this  sinus  is  evacuated  through  its  opening  more 
readily  in  the  recumbent  i^osition;  jjus  coming  from  the  middle  meatus 
may  be  determined  to  come  from  the  maxillary  sinus  if  it  appears  or 
increases  Avhen  the  head  is  lowered  and  the  face  is  turned  towards  the 
side  examined.  This  brings  the  oriiicc  into  the  most  dependent  position 
and  thus  permits  pus  to  How  out  more  readily.  The  position  is  not 
conducive  to  the  How  of  i)us  fi-oni  the  frontal  sinus  or  the  anterior 
ethmoid  cells. 


18 


OPEEATIVE   SI'RGEKY   OF   THE   XOSE,   THKOAT,   AND   EAR. 


The  maxillary  sinus  may  be  opened  surgically: 

1.  Through  the  alveolar  process  by  removing  a  tooth  or  in  some 
instances  without  the  removal  of  a  tooth. 

2.  Through  the  anterior  wall  (in  the  fossa  canina)  in  the  mouth. 

3.  In  the  middle  or  inferior  meatus,  Avith  or  without  resecting  a 
part  of  the  inferior  turbinate. 

4.  By  cutting  away  a  pait  of  the  margin  of  the  apertura  piri- 
formis through  the  nose  and  continuing  the  excision  bv  removing  a 


SINUS     -     -.^^H 

FRONTALIS            '^?^H 

CELLULA       i 

ETHMOIDALIS 

MEATUS     -'     "' 
NASI      MEDIUS 

^,-  ■ 

CANALIS        ' 
NASOLACRIMALIS 

MEATUS 
NASI      INFERIOR 

\^:/ 


FOSSA      PTERYGOIDEA 


Sagittal   sect  ion   througli   tlie   riglit   side   of   ncise   and   maxillary   sinus. 
External  portion. 


part  of  the  external  wall  of  the  nose  below  the  attachment  of  the  infe- 
rior turbinate  (Canfield's  operation). 

Ethmoid  Cells.— The  ethmoid  cells  are  divided  into  two  groups, 
the  anterior  which  open  into  the  middle  meatus  and  the  posterior  which 
open  above  the  middle  turbinate,  generally  in  the  superior  meatus. 

There  is  no  uniformity  as  to  the  number,  position  or  size  of  the 
cells  in  either  group.  They  lie  in  the  bony  wall  between  the  nasal 
cavities  and  the  orbit,  the  frontal  and  sphenoid  sinuses,  and  between 
the  floor  of  the  cranial  cavitv  and  the  middle  turbinate. 


THE   SflUITCAI.   ANATOMY   OK   THE    XOSE. 


19 


/  SoinoliiiK^s  an  (>lliinoiil  cell  may  cxIimh]  into  tin*  middle  1url)inate 
formiiiij,-  Avlial  is  kiidwn  as  a  (•(nu-lia  liullosa.  Such  a  cell  as  a  rule 
lias  its  o]XMiiii,u-  in  its  upper  ])ai-l,  and  lliereloi-e  draiiia^-e  is  unsatis- 
ractoiy  -when  any  alVeclion  is  jn-eseiii  wliicli  causes  it  1o  fill  u])  with 
lluid.  The  bulla  ellimoidalis  ( (''ius.  7  and  ]'■'<)  ((Uilaius  one  or  more 
ethmoid  cells,  ,i;-enei'ally  helouiiinu-  to  the  anterior  ,t;roup,  althouii,-li  occa- 
sionally one  is  found  opiuiin.i;-  into  the  su])erior  meatus. 

In  the  specimens  illustrated  in  l-'i;;s.  lo  and  !(!,  a  sagittal  section 
has  been  made,  so  as  to  cut  thfou^h  the  anterior  attaclnnent  of  the 


INFUNDI8ULUM       E7 
HOiDALIS      ANTERIOn 


CELLUL/E     ETHMOIDALES     POSTERIORES 


PROCESSUS      UNCINATUS 

CONCHA     NASALIS     rNFEB 


Fi-.  ii;. 

Sagittal   section   tliroush  tlie   riyht   side   (if   tlie   imsi'.      Intciual   portion. 


inferior  turbinate  to  the  maxilla,  which  is  shown  free  except  for  its 
attachment  to  the  palate  bone.  The  middle  turbinate  is  shown  articu- 
lated with  both  the  maxilla  and  palate  bone.  The  uiu-inate  ]n-ocess 
which  assists  in  closing;  up  the  inner  wall  oF  the  maxillary  sinus 
projects  downward  from  the  lateral  nutss  of  the  ethmoid.  As  will 
be  noted  it  ]>ai'takes  in  jiart  of  the  j;-eneral  cellular  arran.nement  of  the 
bone  in  this  ])osition. 

The  frontal  openinii;  into  th(>  iid'undiluduni  ethmoidale  is  M'oII  shown 


20 


OPERATIVE   SritGERY   OF   THE   XOSE,   THROAT,   AND   EAR. 


while  adjacent  aiitei'ior  ethmoidal  cells  are  quite  typical.  I'ehiiid  these 
are  the  posterior  etlinioid  cells,  and  posterior  to  them,  the  sphenoid. 
The  specimen  shows  the  pterygomaxillary  canal  throughout  its 
entire  extent.  It  will  be  observed  that  the  upper  part  of  the  canal, 
where  the  s])henopalatine  ganglion  lies,  may  he  entered  l)y  iDlunging 


NTERIOR 


SALIS     INFERIOR 


MEATUS     NASI      MEDtUS 
Fig.     17. 

Sagittal   seetidii   tlnoiigli  tlie   left   side   of   the  nose  internal   to   that  of 


Figs.  15  and  Ki.     Inner  portion. 


a  needle  into  the   outer  wall   of  the  nose  just   above  the   posterior 
extremity  of  the  middle  turbinate. 

An  ethmoid  cell  lies  anterior  to  the  infundibulum  running  par- 
allel to  it  and  resembling  it  in  shape  and  size.  As  has  been  already 
reported  by  the  writer,  a  probe  is  likely  to  enter  this  particular  type 
of  cell,  giving  the  surgeon  the  impression  that  he  is  in  the  frontal  sinus. 
Sometimes  this  cell  or  another  anterior  ethmoid  cell  may  project  far 
into  the  frontal  sinus.  con.«tituting  what  is  known  as  a  bulla  frontalis. 


TTTK  sri;i;i(Ai.  .\^'.\To^^v  ni-  tiik  xosk. 


21 


Tlu'  ;in:ui,i;ciiii'ii(  of  tlio  i-tlmioiil  laliyriiitli  i.s  sliowii  in  F\<^s.  17 
;iiul  IS,  wliifli  illustrato  llic  two  sidos  oL'  a  sagittal  sfctioii  dI"  the  nasal 
cavity  made  internal  to  the  one  in  the  speeiinen  illustrated  in  tlie  last 
tAvo  figures.  On  one  side  the  ]tosteri()r  ^tortious  of  the  turl)inate  are 
left  Avith  their  articulation  with  the  ]i;dalc  lioiic.  and  on  olliei-  their 
maxillary  attachments  are  preserved. 

Sphenoid  Sinus. — The  figures  show  two  very  large  sphenoid 
sinuses,  tlie  light  extending  nnterioHv  lo  1h(>  loft  side  far  Inn-ond  the 


CONCHA       ,.    -        ^^      ^ 
NASALIS  -                                  A 
SUPERIOR                             J^B 

m 

'^'% 

w-/ 

meatus'                " 
nasi    superior 

CONCHA 
NASALIS     MEDIA       y 

MEATUS     NASI      MEOIUS 

cor 

NASALIS 

JCHA 
INFERIOR 

CELLUL/e 

ETHMOIDALES 

NTERIORES 


/lEATUS      NASI      INFERIOR 


Fig.  18. 

Sagittal  section  tliroiit;li  the  left  siilo  of  flic  nose  iiitein:il  to  tluit  of 
Figs,  l.j  ami  l(i.     ExteniiiJ  portion. 


median  line,  and  the  left  posteriorly  almost  as  far.  The  s]ihenoid 
sinuses  occupy  a  greater  or  less  amount  of  the  body  of  the  f^phenoid. 
'i'he  two  sinuses  are  not  uiiirnnn  in  size,  shape  or  velalinn. 

A  sphenoid  sinus  ina.v  exleiid  liuf  slightly  to  the  oj)])osite  side, 
and  sometimes  it  may  grow  In  such  an  extent  on  the  opposite  side, 
that  the  other  sphenoid  is  reduced  to  an  exceedingly  small  size.  On 
the  other  hand  the  last  posterior  etlinidid  may  almost  entirely  replace 
it.     It  may  extend  almost,  as  far  liaek  as  lh(>  Classerian  ganglion,  and 


22  OPERATIVK  sri:in;i;v  (ik  tiik  nose,  throat,  axd  ear. 

to  tlie  hasilhu-  ])vooess  of  the  occipital,  and  as  far  forward  as  the 
canalis  opticus.  Sphenoid  sinuses  of  various  shapes  and  sizes  are  illus- 
trated in  Figs.  35  to  55. 

The  walls  of  tlie  si^heiioid  sinus  vary  in  thickness  not  only  in 
different  individuals,  but  also  in  the  two  sinuses  of  the  same  head. 
This  statement  pertains  more  especially  to  the  superior  Avail,  the 
effect  of  which  is  to  bring  the  pituitary  body  and  optic  nerves  raucli 


NERVUS      TROCHLEARIS 


PHTHALMICA 


Coronal  section  through  nose  and  orliit  throe  mm.  anterior  to  the  anterior 
wall  of  the  sphenoid  sinuses. 

closer  to  one  sinus  than  to  the  other.  The  external  Avail,  generally  the 
thickest,  lies  betAveen  the  sinus  and  the  middle  cranial  fossa,  and  adjoins 
the  sinus  cavernosus  and  the  carotid  artery.  The  folloAving  nerves  in 
addition  to  the  optic  are  found  in  relation  Avith  the  external  wall,  abdu- 
cens,  oculqmotor,  trochlear,  oijhthalmic  and  maxillary  (Fig.  8). 

The  posterijir  Avail  articulates  Avith  the  basillar  process   of  the 
occipital.    The  inner  Avall  or  septum  simiuni  s])luMio!(lalium  is  frequently 


; 


THE    SlMUiU-AI,   AXATD.MV    (IF    TIIK    XOSK. 


23 


ill  tlio  iiu'dinii  liiii'.  lull  fi-oiii  wlial  lias  alivatly  Ix'cii  slated,  i(  may  be 
I'XfOiMliiiu'iy  iiTc^ular  in   its  jKisitioii.     (Fi.e,'.  HT.) 

Tlio  aiilciiov  A\all  is  in  ivlalioii  witli  tlic  nasal  cavity  (rooossus 
s|iluMin('tlnn()i<lalis)  aiul  tiic  i)ost(>rior  ollmioidal  i-cll.  Tii  tlio  soction 
(V\iX.  1i')  llio  -walls  of  tlie  nasal  cavitios  liavc  Ihmmi  ciil  away  :;  iiini. 
aiiti'i-ior  to  the  sinus,  showing  tin'  i-elatioii  of  llu'  autciior  wall  tn  the 
nasal  cavities  and  the  posterior  ethmoid  cells.  I'lu'  turbinates,  four 
in  nuniher  on  each  side  are  ent  elose  to  their  jiosteiior  extremity.  The 
choaTia^  are  A'isible  in  the  depths.  Thi'ir  |Hisiti(in  with  I'espect  to  the 
sphenoid  sinus  and  to  the  jiosterior  portion  of  the  nasal  cavity  is  well 
shown.  It  will  be  observed  that  much  of  the  nasal  cavity  lies  al)ove 
the  clioana>,  quite  as  gi-eat  in  size  from  below  upward  as  the  choaufc 
themselves.  This  (inure  shows  how  the  s])heiioid  may  be  opened  with 
or  without  the  destruction  of  the  posterioi-  ethmoid  cell.  Compare 
this  with  P^'if;-.  8,  Avhich  ^ives  a  view  of  the  sjihenoid  anteriorly  from 
the  ]iharynx. 

The  orifice  of  the  s])henoid  sinus,  while  always  opening'  into  the 
nose  above  the  superior  turbinate,  varies  considerably  in  its  jiosition. 
The  follow-in^'  table  shows  the  distance  between  the  inferior  marf;-in  of 
the  opening-,  and  the  lowest  level  of  the  lloor,  and  the  highest  level  of 
tiie  roof  respectively,  in  fifteen  heads  measured  by  the  writei-: 

DISTAXCK    BKTWKKX    THK    IXFKI.'TOi;    .MAIiClX    OF    TllK    X.\.SAL    OrKXING    OF 
THE  SPJIKXOII)  SlXrs  AXD  TIIK   FLOOR  AXI)  HOOF  OF  THE  SIXL'S 

(In   Millimotors) 


HEADS 

KIGIIT 

LEKT 

FLOOR 

ROOP 

FLOOR 

i;ooK 

VI. 

17 

13 

13 

11 

VII. 

7 

15 

20 

14 

vni. 

i;! 

14 

11 

16 

IX. 

10 

13 

4 

13 

X. 

];} 

9 

8 

12 

XI. 

12 

14 

11 

15 

XII. 

■I 

4 

14 

12 

XIII. 

ir, 

21 

17 

19 

XIV. 

If) 

22 

8 

10 

XV. 

2 

2 

14 

13 

XVI. 

7 

14 

3 

7 

XVII. 

12 

12 

7 

12 

XVIII. 

6 

4 

5 

14 

XIX. 

21 

7 

9 

8 

XX. 

lit 

2 

17 

10 

24  OPF.r.ATIVE    SI'RGKnV    OF   THE    XOSE,    THROAT.    AND   EAR. 

Tliose  fifi-ures  show  a  \vi(l('  variation,  and  yet  it  may  be  said  that 
tlic  (irifieo,  as  a  rnlo,  is  midway  between  the  roof  and  the  floor.  This  is 
true  for  twenty  out  of  thiriy  sinuses. 

In  XIX,  XX,  right,  the  orifice  is  in  the  u]i|iei-  Uiii-d;  in  vii  and  xvi, 
right,  and  ix.  xvr  and  xvni.  left,  it  is  in  the  lower  thiid:  in  thf  dthcr 
twenty-three  instances  it  is  in  the  middle  third. 

It  is  relatively  highest  in  head  xx,  right,  where  its  distance  from 
the  roof  is  one-tenth  of  that  between  the  roof  and  the  floor.  It  is  rela- 
tively loAvest  in  ix,  left,  where  it  opens  in  the  lower  quarter  of  the 
anterior  Avail. 

The  relation  of  the  cavernous  sinus  and  of  the  third  foculoniotoi'- 
ius),  fourth  (trochlearis),  fifth  (trigeminus),  sixth  (abdueens)  and  the 
vidian  nerves  to  the  spher(oid  sinus  has  been  carefully  studied  by 
Sluder. 

He  found  that  the  body  of  the  sphenoid  is  covered  altove  and 
laterally  by  the  dura  mater  with  the  cavernous  sinus  between  its  ex- 
ternal and  internal  surfaces,  occupying  a  position  for  the  most  part 
above  and  lateral  to  the  body.  Within  the  cavernous  sinus  are  found 
the  internal  carotid  artery,  and  the  third,  fourth  and  sixth  cranial 
nerves,  the  first  division  of  the  fifth  lying  in  the  lower  part  of  its  lateral 
wall.  The  sixth  and  third  division  of  the  fifth  are  the  only  ones  of 
these  nerves  that  are  not  at  times  in  close  association  with  this  cell, 
that  is,  separated  from  it  by  a  very  thin  layer  of  bone,  and  even  the 
third  division  of  the  fifth  is  sometimes  also  in  close  association  with 
it.  The  sixth  is  uniformly  placed  on  the  lateral  aspect  of  the  carotid 
while  within  the  cavernous  sinus  and  is  ahvays  removed  from  this  bony 
wall. 

The  fact  Avhich  determines  the  relations  of  these  nerve  trunks  to 
the  sphenoid  sinus  is  the  size  of  the  cavei'nous  sinus  rather  than  the 
size  of  the  sphenoid  sinus.  A  large  sphenoid  sinus  prolonged  back- 
Avard  and  outward  may  closely  approach  the  third  division  of  the  fifth 
in  the  foramen  OA^ale  or  even  the  Gasserian  ganglion.     (See  Fig.  47.) 

The  second  division  of  the  fifth  is  in  close  association  with  the 
sphenoid  sinus  when  it  extends  laterally  to  the  foramen  rotundum. 
The  first  division  of  tiie  fifth  comes  into  close  association  Avitli  the 
sphenoid  sinus  anteriorly  when  the  cavernous  sinus  is  small  in  either 
direction.  The  third  and  fourth  nerves  may  be  in  relation  with  the 
sphenoid  sinus  when  it  is  prolonged  outward  into  the  anterior  clinoid 
process  or  lesser  Aving  of  the  sphenoid.  The  sixth  nerve  comes  into 
these  relations  in  the  sphenoidal  fissure  (fissura  orbitalis  superior) 
AA'hen  the  sinus  is  prolonged  into  the  great  Aving  of  the  sphenoid  (ala 
magna). 

This  close  association  of  the  sphenoid  sinus  Avith  the  second  di- 


TIIK    SriKIICAI.    AXATllMV    dl'    ■lllK    XOSK 


25 


Fijr.  :;n.     (Iload  A'l.) 


Fig.  121.      I  II.M.l   VII.) 


Fig.  •.'•.'.      (Urad  VIII.) 
Lateral  and  »ii[ii>iior  ioo4iiistmirtii>iis  of  the  accessory  siiui<<cs  of  the  n<i.«e. 


26  OPEKATIVE    Srr.dKIIV    (IF    TIIK    NOSK,    THROAT,    A^'O    EMI. 


Fig-.  ■2:',.     (Head  IX.) 


Fig.  i;4.    ^H<•!la  x.) 


Fig.  25.     (Head  XI.) 
Lalcral  and  supeiiiir  roi-onstiuctions  of  (lie  accessory  sinuses  of  the  nose. 


THE   SnUUCAL   ANATOMY   OK   TllK    XOSK 


Fig.  20.     (Jleaa  XII.) 


Fig.  27.     (Hoad  XIII.) 


I-'ig.  28.     (Iloii.l   XIV.  1 
Lateral  ami  superior  rcoonsi  met  inns  of  tlio  aecessory  sinuses  of  tlie  nose. 


28  OPEIIATIVE    SnUiERY    OK    THE    XO.SE,    THROAT,    AXI)    EAR. 


^'        .-J) 


"-0 


Fig.  19.     (Head  XV.) 


-t^ 


Fig.  :;0.     (Head  XVI. 


Fig.  ;U.     (Head  XVII.) 
Lateral  and  superior  recoiistractions  of  the  acfcssory  sinuses  of  the  nose. 


THE   Sl'KCK'AI.   ANATOMY    Ol'   TIIK    NOSE. 


29 


Fig.  32.     (Head  X^^II.) 


Fig.  3;;.     (Head  XIX.) 


Fig.  .11.     (Head  XX.) 
Lateral  and  sup<>rior  ree^nstxurf  ions  of  the  awossorv  sinuses  of  tlic  nose. 


30 


OTKltATIVK    sri:iiKi;V    (tK    THE    XOSE,    TIIIIOAT,    AXL)    EAR. 


visidii  t>r  tlic  lillli  ill  llic  roianieu  rotunduin  may  be  estalilishod  as  cai'ly 
as  llic  Ihiid  year  of  lire,  and  witli  tlie  vidian  nerve  in  its  canal  as  early 
as  the  si.\lli  year. 

Variations  of  the  Sinuses  in  Size  and  Shape. 

Tlie  reeonstriu'lion  nietliud  is  perliaps  the  best  for  ilhistratina,'  the 
variations  in  size  and  shape  of  the  sinuses.  Eeconstructions  of  the 
simises  in  fifteen  heads  are  shown,  riglit,  k^ft  and  snperioi".  In  Figs.  20 
to  34  inclusive,  the  central  illustration  is  the  superior  view,  tlie  right 
shows  the  left  set  of  sinuses,  and  the  left  the  right  set  (so  placed  in 
order  to  make  orientation  easy).  The  anterior  ethmoid  cells  are  repre- 
sented by  dotted  lines  and  tlie  posterior  by  broken  lines.  The  other 
sinuses  are  drawn  with  solid  lines,  as  they  are  ol)vious,  viz.,  in  the 
central  illustration  the  maxillary  are  the  most  external,  the  frontal  an- 
terior, and  the  sphenoid  ])osterior;  in  the  lateral,  the  frontal  is  supe- 
rioi-,  the  sphenoid  posterior,  and  the  maxillary  infi'rior.  The  ethmoid 
cells  of  each  group  are  drawn  as  if  they  constituted  a  single  sinus, 
excei^t  Avhere  the  cells  were  too  far  distant  from  the  group.  As  the 
figures  are  reduced  to  one-half  the  natural  size,  it  is  easy  to  estimate 
the  extent  of  the  sinuses. 

In  the  central  figures  the  extent  of  the  sinuses  anteroiiosteriorly 
and  laterally  is  shown,  and  in  the  right  and  left  figures,  superoin- 
■feriorly  and  anteropostei-iorly.  The  corresi)onding  diameters  may  be 
thr;s  determined. 

Frontal  Sinus.— AVhile  there  is  a  great  diversity  of  shapes  to  be 
found  in  the  different  fi'ontal  sinuses,  there  is  rather  more  imiformity 
of  shape  and  size  in  the  two  fi-ontals  of  the  same  head.  The  dimen- 
.sions  in  millimeters  are  as  follows: 

DIAMETERS  OF  THE  FRONTAL  SINUS 
(In   Millimptcrs) 


irEAD 

ANTEROPOSTERIOR 

SUI'KROINFERIOR 

LATERAL 

R. 

L. 

R. 

L. 

R. 

L. 

vt. 

15 

18 

24 

30 

20 

32 

VII. 

32 

33 

28 

26 

22 

26 

A'lII. 

22 

Ifi 

51 

28 

25 

11 

IX. 

17 

21 

27 

36 

21 

37 

X. 

17 

17 

40 

37 

27 

22 

XL 

22 

16 

38 

38 

22 

15 

XII. 

16 

22 

34 

45 

10 

27 

XIIL 

17 

13 

25 

22 

21 

18 

XIV. 

2(1 

21 

45 

37 

42 

37 

XV. 

9 

12 

14 

24 

7 

11 

XVI. 

12 

13 

35 

30 

26 

21 

XVIL 

2() 

30 

35 

43 

17 

23 

XIX. 

28 

21 

39 

41 

25 

30 

XVIII. 

12 

17 

30 

31 

28 

20 

XX. 

2G 

31 

46 

45 

32 

24 

THE  srruiU'Ar,  axatiimy  oi'  thk  xosk. 


31 


The  varintidiis  in  llic  size  of  llir  iVmilnls  iii;iy  lie  siiniincil  u))  as 
I'lilldw  s: 

Ran.u'f.  aiilri-()|)()stcri(ir  !•  to  .'!.'!.  siiiicrninfciici-  14  to  ."il.  ladTal  7 
to  42.  I'siial.  Icaviim-  lUil  live  liiuiicsl  ami  lowest,  aiili'i-oposlcrior  l.'j 
to  ll(i.  supcidiurciior  iM  (o  -10.  lalrral  17  lo  '-'A).  Avcranc  aiitcro- 
])oslci'ior  iM.  suiM'i'oiiircrior  .■)4.  laliTal  '_')'>. 

'i'lii'  larui'sl  .-iiius  is  lliat  of  \i\  (  I^'Il;-.  L'S  )  riL^iit.  in  wliii-h  the 
(lianic'ti'i-s  ai-r  I'l;.  4.").  4l'.  and  llir  sinallcsl  llial  of  w  (  l^'it;-.  I'll)  rii;-h(, 
liaxini;-  tlir  ilianicliTs  1'.    14.  7. 

Maxillary  Sinus.  As  a  r\ilc  the  maxillary  sinuses  in  a  .uivcn  lioad 
arc  I'airly  uiiil'orMi  in  size  and  sliai^';  the  dimensions  of  the  maxillary 
siniise.«J  arc  sliowii  in  tlio  following'  table: 


DIA.METKRS  OF  THK  .MAMLLAKV  SIM.S  AM)  IJISTA-NCK  OF  TJIK  OlMiMXC  FROM 
THE  FLOOR  OF  THE  CAVITY 

(In    ^nilimrtrrs^ 


— 

DISTANCE  OF 

ANTLi;u 
I'OSTKIUOK 

INFERIOR 

I,.\TKRAL 

OPKXINO  FROM 
FLOOR  OF  CAVITY 

IlKAIl 

R. 

L. 

E. 

L. 

R. 

L. 

R. 

L. 

VI. 

39 

40 

42 

32 

30 

25 

36 

28 

VII. 

40 

42 

41 

47 

28 

29 

32 

39 

VIII. 

.32 

30 

28 

29 

19 

IS 

24 

25 

IX. 

17 

20 

17 

21 

S 

11 

15 

14 

.\. 

39 

37 

37 

40 

3."! 

30 

36 

38 

XI. 

40 

40 

37 

39 

31 

29 

33 

34 

XII. 

34 

29 

28 

28 

28 

25 

21 

23 

XIII. 

37 

40 

45 

43 

29 

32 

32 

32 

.\IV. 

37 

42 

38 

40 

25 

25 

23 

21 

XV. 

40 

33 

38 

34 

24 

20 

33 

30 

XVI. 

25 

26 

23 

26 

15 

17 

18 

24 

XVII. 

?,r, 

37 

31 

33 

32 

23 

22 

25 

XVIII. 

:\r, 

2C 

38 

26 

26 

19 

33 

21 

XIX. 

3() 

42 

45 

42 

27 

32 

40 

38 

XX. 

3fi 

35 

39 

36 

25 

21 

36 

28 

The  \a  rial  ions  are  as  follows: 

Ran,u:o,  antcroposteiior  diameter  17  to  4l',  snperoiiifcrior  17  to  47, 
lateral  8  to  .'^:>,  oi-ificf  to  lln,,r  14  lo  4(1.  Isiial.  h  a\ing-  off  liighost  and 
lowest  five,  anteroposterior  '2'J  to  40.  snperoinferior  28  to  42,  lateral 
111  to  oO.  oritk-c  to  lloor  21  to  oli.  .\\i'iag<  .  anlero|iost('ri()r  IW,  snpero- 
inferior 38,  lateral  23.8,  orifice  to  floor  2!).  The  largest  is  vii  (Fig.  21) 
left.  42.  47.  2!).  the  smallest  is  ix  (  Fig.  2:;)  riglit.  17.  17.  S.  If  will  be 
Moled  ilijil  leaxiiiL:'  (Mil  a  few-  of  the  extremes,  tln'  inaxillary  sinuses  are 
mure  unifoi-m  than  anv  of  the  other  sinuses. 


32 


nPKIIATIVK    SXTUIKUV    OK    TITE    XOSK,    THROAT,    AM)    KAK 


Ethmoid  Cells. — To  show  Ww  nivat  coinplcxity  of  tlic  I'llimoid  cells 
aii<l  llic  \ai-ialiilily  of  llii'ir  si'/.c  and  slia])(',  it  lias  been  (Ii'ciiumI  advis- 
able to  consider  the  diameters  of  the  ethmoid  labyrinth  and  of  the  an- 
terior and  posterior  groups  of  colls  respectively.  The  dimensions  are 
as  follows: 

DIAMETERS  OF  THE  ETHMOID  LABYRINTH 

(In   Millimctrrs) 


LABYRINTH 

AXTEBIOR  ETHMOID 

POSTERIOR   ETHMOID 

HEAD 

2  1 

a    o 

c 

m 

s 

2  1 

°   o 

J5 

J 

< 

S 

il 

1 
1 

VI. 

Risl.t 

37 

23 

18 

23 

22 

8 

28 

23 

28 

Left 

36 

20 

13 

22 

15 

9 

20 

17 

12 

VII. 

Right 

43 

34 

26 

22 

31 

8 

26 

34 

27 

Left 

47 

35 

20 

27 

12 

9 

30 

36 

20 

Yiir. 

Ri-ht 

32 

26 

19 

32 

20 

16 

22 

17 

11 

Left 

47 

32 

26 

24 

25 

11 

22 

32 

26 

IX. 

Rio-ht 

34 

39 

20 

21 

33 

18 

23 

26  ■ 

12 

Left 

30 

3(3 

20 

20 

32 

19 

21 

28 

23 

X. 

Rioiit 

35 

28 

14 

19 

25 

11 

20 

17 

13 

Left 

35 

28 

15 

21 

26 

15 

22 

19 

14 

XI. 

Right 

24 

33 

15 

10 

26 

11 

20 

IS 

13 

Left 

2'^ 

29 

16 

14 

27 

11 

17 

15 

16 

XII. 

Right 

40 

20 

12 

40 

17 

12 

15 

6 

8 

Left 

34 

17 

12 

30 

17 

9 

13 

10 

11 

XIII. 

Right 

35 

31 

12 

14 

18 

9 

26 

23 

12 

Left 

35 

35 

IS 

26 

35 

14 

25 

31 

IS 

XIV. 

Right 

45 

59 

26 

26 

57 

26 

27 

30 

17 

Left 

46 

57 

28 

30 

50 

29 

32 

31 

12 

XV. 

Right 

33 

26 

9 

9 

7 

24 

24 

20 

9 

Left 

37 

26 

11 

17 

8 

26 

20 

11 

XVI. 

Rigiit 

32 

40 

15 

20 

35 

14 

22 

•10, 

12 

Left 

35 

31 

22 

19 

2S 

18 

28 

23 

16 

XVII. 

Right 

27 

19 

12 

9 

19 

7 

IS 

17 

11 

Left 

22 

IS 

10 

12 

16 

10 

16 

17 

10 

XVIII. 

Right 

54 

33 

16 

22 

18 

14 

14 

28 

15 

Left 

38 

25 

15 

30 

34 

12 

33 

23 

15 

XIX. 

Right 

24 

25 

11 

10 

25 

13 

17 

IS 

11 

Left 

25 

28 

11 

15 

28 

11 

17 

20 

9 

XX. 

Right 

35 

40 

15 

28 

38 

11 

27 

35 

14 

Left 

32 

42 

13 

15 

29 

12 

25 

38 

13 

These  figaires  show  the  following: 

Etlimoid  Labyrinth. — Range,  anteroposterior  diameter  22  to  54, 
superoinferior  17  to  59,  lateral  9  to  28.  Usual,  leaving  out  five  highest 
and  lowest,  anteroposterior  27  to  43,  superoinferior  23  to  36,  lateral  12 
to  20.     Average,  anteroposterior  35,  superoinferior  31.6,  lateral  16.3. 

The  largest  is  that  of  xiv  (Fig.  28)  left,  46,  57,  28,  and  the  small- 
est, XVII  (Fig.  31)  left,  22,  18,  10. 


TlIK    SriUilCAI.   ANATOMY    OK     llIK    XOSK. 


33 


Anterior  Ethmoid.  IJaimv.  nnttTdiin-l.Tidi-  !»  to  -in.  Mi|MT(.iiircrior 
7  t.>  ."i7.  lateral  7  to  l'!).  I'siial.  l<>a\iiiL;-  nut  li\r  liiuln-st  ami  lowi'st. 
anti'i(i|iosterior  14  to  127,  suporoiiifcriDr  17  In  '.U.  laliial  It  In  IS.  Avcv- 
agc,  anteroposterior  21,  siiperoiiil'erid:-  lTi.Ti.  latiial   14. 

The  largest  is  that  ol'  xiv  (  l''i-.  i:S)  left,  ;;().  .Id.  I'i),  and  the  small- 
est that  of  XVII  (Fi-.  'M)  rigiit,  !).  \\K  7. 

Posterior  Etlunoid. — Range,  anlcioiMJstcriDr  K!  to  '.]'.],  snpero- 
iuL'erior  G  to  38,  lateral  8  to  28.  Usual,  leavinii'  nut  live  highest  and 
lowest,  anteroposterior  17  to  26,  superoinferioi-  17  to  .■!1,  lateral  11  to 
18.     Average,  anteroposterior,  22.3,  superointerior  23.3,  lateral  14.7. 

The  largest  is  that  ol"  vii  (Fig.  2(5)  left,  30,  3G,  20,  and  (he  smallest 
that  of  XII  (Fig.  20)  right,  15,  6,  8. 

Sphenoid  Sinus.-  'riier(>  is  a  Iremeiidnns  variation  in  1h(>  dimen- 
sions ol'  the  thirty  sphenoid  sinuses,  as  sliowii  iu  the   rollnwiui;-  tahle: 

DIAMICTKKS  OF  TIIK  Sl'llK.NOlU  SINUSES 
(In  Millimeters) 


HEAD 

ANTEROPOSTERIOR 

SUPEROINFERIOR 

LATERAL 

R. 

L. 

R. 

L. 

R. 

L. 

VI. 

35 

15 

30 

24 

31 

12 

Vll. 

42 

36 

22 

34 

34 

25 

VIII. 

25 

20 

27 

25 

16 

12 

IX. 

21 

14 

23 

17 

17 

13 

X. 

17 

14 

22 

20 

17 

11 

XI. 

.•51 

27 

26 

2() 

14 

19 

XII. 

9 

.•J9 

8 

26 

7 

24 

XIII. 

1(5 

?,?, 

36 

36 

14 

27 

XIV. 

24 

10 

38 

IS 

35 

10 

XV. 

2 

2;! 

4 

27 

2 

21 

X  \'  I . 

•20 

0 

21 

ni 

14 

S 

XVll. 

24 

14 

21 

ni 

17 

17 

XVIII. 

9 

19 

10 

I'.i 

ii 

24 

XIX. 

32 

20 

28 

17 

27 

12 

XX. 

29 

30 

21 

27 

28 

34 

The  anteroposteri<ii-  diameter  varies  from  2  mm.  in  xv  (Fig.  29) 
liiiht,  to  42  mm.  in  vu  (Fig.  21)  i-ighl  :  the  superoinrerior  from  4  in  xv 
(  i-'ig.  29)  right,  to  38  in  xiv  (Fig.  28)  ii,-ht  :  lateral  from  2  in  xv  (Fig. 
29)  right,  to  33  in  xiii  (Fig.  27)  right. 

The  sphenoid  sinus  of  xv  {V'lix.  29)  iii;lit,  is  hy  far  the  smallest, 
with  diameters  2,  4  and  2:  the  mxt  smalh'st  heing  xii  (Fig.  26)  right, 
with  diameters  9,  8  and  7.  That  of  \ii  I  l-'ii;-.  21)  right,  is  the  largest, 
with  diameters  42,  22  and  34;  whWr  that  of  vi  (Fig.  20)  right,  is  next 
lai-,u-est,  with  diameters  3.",  .'If)  and  '.'A. 


34 


OPERATIVE    ST'RGEnV    (IK    TlfK    XIISK.    Tlll'.OAT.    AXU    EAR. 


The  average  diameters  of  tlie  thirty  sinuses  are  as  foUows: 
Anteroposterior  21.5,  superoinferior  22.8,  lateral  18.4.  Excluding  five 
cxtrcines,  smallest  and  hirgcst,  tlic  i-aiigc  nl'  (he  remaining  twenty, 
■\vliich  may  be  consichTed  as  roiiinioii,  is  as  L'odows:  Anteroposterior 
14  to  32,  superoinferior  17  to  27,  latei'al  11  to  27. 


Fig.  35.     (Head  \^I.) 
Phister  casts  of  sphenoid  sinuses,  placed   in   situ. 


A  glance  at  the  reconstruction  of  the  sphenoid  sinuses  (Figs.  20 
to  34)  shows  the  great  variety  of  size  and  shape.  The  right  sphenoid 
XV  (Fig.  29)  is  but  little  larger  than  its  opening  into  the  nasal  cavity, 
■which  is  in  its  accustomed  position.  It  is  replaced  almost  entirely  by 
the  left  sphenoid,  wliich  is  in  relation  -witli  the  optic  chiasm,  and  lioth 
nerves.  Both  sphenoids  of  vii  are  exceedingly  large  (Fig.  21)  and 
extend  far  liehind  the  optic  chiasm,  shiirini;-  this  feature  witli  vi  (Fig. 


TIIK   snunCAL   AXATO.MV   OK   TIIK    XO.SE.  35 

I'd)   rii-lit.  XII   (Fii--.  L'(i)   left.  Ml!   (Kin-.  1'7 )   Idt.  wii    (  I-'ii;-.  :{1  )    ri-lit, 
ami  XIX  (Fi.n-.  33)  rislit. 

Tlioro  is  likowiso  ureal  disiiarity  in  the  size  of  flic  two  splii'iiiml 


Fig.  3«.     (lload  XII.) 
PliLsU-r  casls  of  sphenoid  sinuses,  ]ilaoC(l  in  silu. 


.minuses  in  vi  (Ki-   20),  xii  ( Ki-    2(i).  mv  (  Fi-.  -.N).  xv  (Fi-    2!))  aii.l 
XIX  (Fig.  33). 

In  xvr  iioitlicr  .^plionoicl  i.';  in  relation  witli  tlie  Icll  optic  norvo 
(Fi.ir.  30).  A  largo  posterior  ylliinoid  cell  icplaros  tlio  loft  splionoid 
which  is  gn-atlv  rc<lii,-iMl  in  sizo. 


36  nPKHATIVK    snUiERY   OF   THE    NOSE,    TllltOAT,    AND    EAI!. 

Superficial  Area  and  Cubical  Capacity  of  the  Sinuses. 

Ill  ordrr  to  (leteriuiiic   the   supci'licial  area   and   ciiliical    rapacity 
oi"  the  minuses,  it  is  lU'oessavy  to  mak(>  casts  of  tliciii  and  sulijcct  these 


Fig-.  37.     (Head  XIV.) 
Plaster  easts  of  sphenoid  sinu.ses,  jilaced  iu  situ. 


to  some  standard  of  measurements.  Branne  and  Clasen  found  the 
cubical  capacity  by  volumetric  measurements  of  metallic  casts  of  the 
sinuses.    The  writer  presented  a  method  at  tlie  International  Laryngo- 


THE   srr.tilCAL   ANATOMY   OK   THE   NOSE. 


37 


niiinolosieal  Cougross  in  Berlin  in  l!»ll.  by  wiiidi  l>ntli  IIh'  ciil.icMl 
capacity  and  tlio  siiporlicial  area  ( Tor  tlic  lirsl  tinn')  wnr  (l.'lcrniiiialili' 
from  iilastcM-  casts  made  of  llic  sinuses  (r\cc|il  the  rtlnnnidal)  in  serial 
sections,  and  tlien  properly  united  according;'  In  the  iiieijinds  used  by 


Fig.  38.     (Head  XXIII.) 
Pliistor  cnsts  of  splionoid  sinuses,  jilaccd  in  situ. 


dentists.    A  number  of  illustrations  of  such  casts  of  the  sphenoids  are 
hero  presented,  the  casts  beina;  placed  in  jirojier  position  in  the  lowest 

section.     A  far  lictter  understandinii'  nl'  (1 \leiit   and  varial)ility  of 

llie   sphenoid  sinuses   is  s(!cured   liy    this    nieiiied    than    by   any   other. 


38 


()n:i;.\TivK  srncKiiv  ok  the  nose,  throat,  axd  eau. 


It  will  bo  observed  that  the  splienoid  sinuses  although  sliowing  little 
resemblance  to  one  another  in  the  different  heads,  are  fairly  uniform 

in  sliape  and  size  in  vii  (Fig.  o.")),  xxiii  (Fig.  38)  and  xxxv  (Fig.  40). 


Fig.   .-ii).      (HL'.-ia  XXVI.) 
Plaster  casts  of  s|ilionoiil  sinuses,  plareil   in   situ. 


These  are  all  large  except  xxiii.  The  greatest  difference  is  to  be  seen 
in  XII  (Fig.  36)  in  which  tlie  riglit  sphenoid  is  reduced  to  a  cavity  2  by  2 
by  4  mm.    xiv  (Fig.  37)  and  xxvi  (Fig.  39)  show  considerable  difference 

in  the  size  of  the  two  splienoids. 


TlIK    srivdlCAI,   ANATOMY    Ol'   TIIU    NOSK.  3!) 

Tlio  results  of  till'  iiirasiiii'iiii'iits  iiia\'  lif  suiiimaii/<'<l  as  I'nllows: 


SIl'EltKlCIAL    AKKA    IN 
SlJI'AltK  rKXTlMKTElIS 

1  rUICAL  CAPACITY  IX 
iTBIC   CEXTIMETERS 

Greatest 

Leas! 

i.M-atcst 

Least 

Splieiioiil, 

Frontiil, 

Maxillary, 

2S.2 

2.1 
5.5 
12.1 

11.8 

8.2 

28.4 

0.6 
0.9 
4.5 

Vig.   10.      (Head   XXXV.) 
Piaster  casts  of  splii'iuiiil  sinuses,  iilaceil  in  situ. 


40 


Di'KRATivK  sri;(;Ki;v  of  ttik  xosk,  TiinoAT,  Axn  eak. 


Optic  Chiasm  and  Nerve. 

The  relation  of  these  si  nictures  to  Hie  nose  and  accessory  sinuses 
is  oC  importance  I'l-oin  tlie  stamliioinl  of  both  palholoii'v  and  snrgery. 


SINUS      FRONTALIS     SINISTER  SINUS      FRONTALIS     DEXTER 


SINUS     SPHENOIDALIS     SINISTER  / 


ARTERIA      CAROTIS      INTERNA 


Fi.n'.  -U.      (Head  VI.) 
Pieparatidii  showiui;'  lelation  of  optic  iierxo  to  acf.essoiy  siiiuses  of  tlie  nose. 

SINUS      FRONTALIS     SINISTER  SINUS      FRONTALIS      DEXTER 


CELLUL>e 

ETHMOIDALES 
^.       POSTERIORES 


SPHENOIDALIS     SINISTER 


iRIA      CAROTIS       INTEF 


aTERIA      CAROTI! 


Fig.   42.      (Head  YII.) 
Preparation  slunvini,'  relation  of  optic  nerve  to  acc-essory  sinuses  of  the  nose. 


TIIK    SllUMCAl,    ANATOMY    (H      IIIK    NOSE. 


41 


'I'lic  autlior  lias  inado  a  study  ol"  this  in  the  liftccn  heads  ilhist rated 
in  Fiiis.  41  to  55  inclusive.  These  are  the  same  heads  of  which  recon- 
slruclicns  were  made  as  shown  in  Fiij-s.  20  to  114  inclusive. 


SINUS     FHONTALIS     SINISTER  SINUS     FRONTALIS     DEXTER 


',       -=^5^ 


g-  r  ?'  m 


ARTERIA     CAROTIS      INTERNA 


ARTERIA     CAROTIS      INTERNA 

Fig.  43.     (llciid  VHI.i 
l*r«'|i:ii;itiiJii  sliowiii;,'  lel.'Vtion  of  ojilie  nerve  tn  aci  rssiiiy  sinusps  ol'  llio  ikisc. 


SINUS      FRONTALIS     SINISTER  SINUS      FRONTALIS      DEXTEF 


NERVUS      OCULOMOTORIUS 


SPHENOIOALIS      DEXTER 

ARTERIA 
•.  CAROTIS      INTERNA 

NERVUS      OCULOMOTORIUS 
sella'   TURCICA 


Fi;;.    14.     (llca.1  I.\.) 
^liow-ing  rt'l:itio!i  '■'  ....<;.•  iirrvc  to  accessory  suiuscs  of  thi.'  nose. 


42 


oPKitATivK  s^■|!(;I••,l;^■  ok  tiik  nose,  -I'liitoAT,  .\m>  kai;. 


The  o]itif  c'l)iasiii  in  llicsc  lic-ids  is  in  llic  main  in  i-clation  with  one 
or  botli  p])hen()i(l  simiscs.  it  is  diicctly  n|Min  ihc  roof  in  heads  vi  {Fis;. 
41 )  lidlli  sides:  VII  (  Ki-  41')  :  xii  (  Ki^.  47)  lioth  sides:  xiii  (Fin-.  4s^)  left: 


CELLULA 

ETHMOIDALIS 

POSTERIOR 


^RTERIA      CAROTIS      INTERNA 


ARTERIA      CAROTIS      INTERNA 


Fi--.  4.5.      (Head  X.) 
Preparation  slnnviii;L;'  reljitioii  of  optie  nervo  to  nf'C^ssoiy  sinuses  of  tlie  nose. 


MUS      FRONTALIS      SINISTER  SINUS      FRONTALIS      DEXTER 

V  '  LAMINA      CRIBROSA 


CAROTIS       INTER 


NERVUS       OCULOMOTORIL 


NERVUS      OCULOMOTOR  I  US 


Fig.   A6.      (Hea.l  XI.) 
Prpjt;i.i:itinn  showiii;^-  lelution  of  ojitic  nerve  to  accessory  sinuses  of  tiie  nose. 


THE  srr.cicAi.  ANAiti.\n   m    tiik  xosk. 


43 


XV  (  Kiy.  :)())  left:  xvii  (  Fiii'.  'y2)  riulit ;  win  (Vi>x.  'il])  Idl;  mx  {Fi'j;. 
')4)  liotli  sulos. 

It  lies  coiisiil('ral)ly  iihovr  tlic  iimiI'  in  \iii  (  I-'Il;-.  43)  left:  xiv  (Fig. 
40)  loft:  XVI  (Fig.  51)  loft. 

It  lies  postoriov  to  the  si)iiciioi(l  simis  in  via  (Fig.  43)  both  sides; 
IX  (Fig.  44)  both  sides:  x  (Fig.  45)  both  sides;  xi  (Fig.  46)  both  sides: 
xiii  (F^ig.  48)  right:  xiv  (Fig.  49)  both  sides;  xvi  (Fig.  51)  both  sides: 
XVII  (Fig.  52)  left:  xx  (Fig.  .55)  both  sides. 

It  is  thus  seen  llial  in  more  than  half  nf  tlie  instances  the  chiasm 
lies  posterior  to  th(>  sphcndid  cavitx.  Sjirrial  attention  is  called  to 
VI,  VII.  XII.  xiii.  XVII.  xi\.  wlicri'  a  coiisidcraliic  portion  of  the  sphenoid 
cavity  lies  beyond  tin^  anterior  margin  i>\'  the  optic  chiasm.  Xo  other 
cells  among  tliese  specimens  come  into  iclatinn  with  the  optic  chiasm. 

Tlie  optic  nerve  may  be  described  as  ))assing  externally  from'  the 
ehiasm  along  the  roof  or  lateral  wall  of  the  sphenoid  sinns  in  slight 
relation,  usually  with  the  last  ])osterioi'  itlnnoiil  cell,  .ind  iVoiii  tlience 
to  the  ])ulbns  opticus  through  tlie  perioiliita. 

Tt  may  be  divided  into  a  sinus  iioitimi  ami  a  \'r('o  portion,  riidei- 
the  former  term,  I  include  that  jiart  of  tlic  m  rve  in  iiiunediate  relation 
with  the  accessory  cavities  of  ll:e  nose  or  ( arliit  i-aiily )  \\itliin  o  timi. 
of  the  simis  wall. 

The  following  nieasuremenls  show  (he  length  of  tlie  nerve  in  the 
ililTei-eiit  heads : 


I.KXGTH  OF  Dl'TlC  XERVK 
(In  Millimeters) 


The  following  variations  are  olitained: 

Optic  nerve:  range,  34  to  55;  usual,  heaving  off  highest  and  lowest 
live,  40  to  48;  average  44. 


44 


oi'i:i;.\ri\  K  snuiKnv  or  tiik  xose.  tiitoat.  axo  kak. 


Free  portions:  raiig-o,  ll^  to  38:  Tisual,  Icavinii-  off  liiulicst  and  low- 
est five.  1")  to  23:  average  20. 

Sinus  portion:  rang-e.  17  to  32:  nsual.  lca\iiiL;-  off  liiuliest  and  low- 
est five.  21  to  28 :  average  24. 

It  is  therefore  clear  tliat.  a(  least  in  these  heads,  the  sinns  iiortion 
of  the  optic  nerve  is  a  trille  greater  tlian  the  free  portion. 

There  does  not  apju'ar  to  be  any  correspondence  between  the 
leiigtli  of  the  optic  nerve  and  the  extei\t  of  accessory  cavities. 

"Where  the  sinus  is  very  large,  the  optic  nerve  has  its  origin  in 
the  chiasm  on  the  roof  of  the  sphenoid,  some  distance  anterior  to  th(> 
posterior  wall  of  the  sinus,  as  for  instance  in  vi  (Fig.  41)  right:  vii 
(Fig.  42)  both  sides;  xii  (Fig.  47)  left:  xiii  (Fig.  48)  both  sides;  xx 
(Fig.  55)  both  sides. 

AVhore  the  sinus  is  small,  the  o]itic  nerve  leaves  the  chiasm  gen- 
erally behind  the  sinns.  as  seen  in  viii  (Fig.  43):  ix  (Fig.  44)  lioth 
sides:  x  (Fig.  45)  both  sides;  xvi  (Fig.  51)  both  sides.  Head  xvrn  (Fig. 
53)  is  somewhat  at  variance  witli  this  rule,  but,  u.iulei-  any  circum- 
stances, it  does  not  appear  possible  to  assign  the  variation  of  thi^  sinus 
as  an  explanation  for  the  varying  size  of  the  optic  nerve,  nor  for  the 
relation  which  the  sphenoid  opening  bears  to  the  optic  nerve. 

The  following  table  of  measurements  shows  this  difference. 


DISTAXCK  BETWEEN  LOWER  SURFACE  OF  OPTIC  XERVE  AXD  XASAL  OPEXIXG 

OF  SPHENOID 
(In   Millimeters) 


HEAD 

RIGHT 

LEFT 

VI. 

9 

6 

ni. 

6 

6 

VIII. 

2 

6 

IX. 

6 

7 

X. 

.S 

2 

XI. 

9 

12 

XII. 

9 

3 

XIII. 

5 

0 

XIV. 

14 

14 

XV. 

S 

5 

XVI. 

12 

11 

XAII. 

5 

5 

XVIII. 

1  above 

2  above 

XIX. 

1  above 

1 

XX. 

S 

12 

Range,  2  above  to  14;  usual,  leaving  off  highest  and  lowest  five, 
2  below  and  11 ;  average  6. 

In  two  instances  xviii  (Fig.  53)  l>oth  sides,  and  xix  (Fig.  54)  right. 


THE   SrRGICAI.   ANATOMY    OK    TMK    NOSE. 


45 


the  orifice  i.s  aljuve  the  Iuwit  sui  lace  oT  tlic  optic,  and  in  xiii  (Fi.ir.  48) 
left,  it  reaches  the  same  level.    In  nine  instances  out  of  the  thirty,  the 


SINUS     FRONTALIS     SINISTER  SINUS     FRONTALIS     DEXTER 

.'  NERVUS     OLFACTORIUS 


CAROTIS      INTERNA 


kRTERIA     CAROTIS      INTERNA 


^'  NERVUS      OCULOMOTORIUS 

NERVUS      OCULOMOTOHIUS 

Fife'.  47.     (Uead  Xll.j 
Preparation  showing  relation  of  optic  nerve  to  accessory  sinuses  of  the  nose. 


SINUS      SPHENOIOALIS      DEXTEI 
ARTERIA      CAROTIS      INTERNA 


NERVUS     TRIGEMINUS 


NERVUS      OCULOMOTOHIUS 


Fig.  48.     (Head  XIII.) 

Prppaiatinn  showin:;   r..l:,i;,,i^  ..f  <.|.ii<-  ii..rv..  ti,  ■ 


M„1W,.«      Ui      ll... 


46 


OPKIIATIVK    srHGERY    Ol'    TIIK    XCISK,    TlfKOAT,    AXD    KAR. 


optic  nerve  lies  witliin  'A  iiiiii.  of  I  lie  level  u\'  the  (ii-ilice  of  tlie  sinus. 
When  the  optic  nerve  lies  sd  near  the  level  of  the  orifice  of  the  sphe- 


ARTERIA     CAROTIS      INTERNA  ARTERIA      CAROTIS      INTERNA 

Fig.  iii.     (Head  XIV.) 
I'lepaifitiiiii   sliiiwing'  leUitiou  of  opiir-  iiCTVc  to  acc^ssoiy  sinuses  of  tlie  nose. 


CAVUM       NAS 


ETMMOIOALIS     POSTERrOR 


ARTERIA      CAROTIS      INTERNA 
ARTERIA     CAROTIS      INTERNA 

Fig.  50.      (Head  XV.) 
Preparation  showing-  relation  of  optic  nerve  to  acc«ssoiy  sinuses  of  tlie  nose. 


THK    sriUllrAI,    .\NAlu\n     UK    TIIK    XOSK.  4( 

nnitl.  it  is  in  a  far  nioi*r  vuliit-ralili'  iH.^iti.ui  than  when  ils  dislancL* 
is  uTcatt'i",  fur  t!if  uritir^'  n'j.irv,.iiis  i  In-  iMtssilili'  liriu'lit  ^)['  jais  in 
si>lM'imid  cniiiN'ciiia  witli  an  oucti  ni-illci'. 


SPMENOIDALIS      DEXTER 
ARTERIA      CAROTIS      INTERNA  ARTERIA      CAROTIS      INTERNA 

Fi^i'.  51.     (,Hea(l  XVI.) 
Preparation  showing  relation  of  optic  nerve  to  accessory  sinuses  of  the  nose. 


SINUS     FRONTALIS     SINISTE 


SINUS      FRONTALIS      DEXTER 


CELLUL>E 
ETMMOIOALES 
ANTERIORES 


CELLUL>e 

HMOIDALES 

■.TERIORES 


SPHENOIOALIS      SINISTE 


if        X         ^v  SINUS 


SPHENOtDALIS      DEXTER 
ARTERIA      CAROTIS      INTERNA 

NERVUS       OCULOMOTORIU8 

Fiji.  5l\      (Hrn.i    \\  I  I.  . 
Preparation  slmwinj;  relation*  of  nplic  lu-rvr  to  ac.'4'ssoiy   -inuses  of'  \ho  nose. 


48 


OPERATIVE   SUKGEltY   OF   THE   NOSE,   TIIKOAT,   AND   EAR. 


The  optic  nerve  as  a  rule  eonies  into  I'clation  Avitli  the  iiostero- 
external  ang'le  of  the  last  posterior  etlunoid  cell  at  its  roof,  and  from 
this  i)oint  It  passes  in  an  (>xternal  direction  lliroun-li  (lie  periorbita  to 


SINUS      FRONTALIS     SINISTER 
LAMINA     CRIBROSA 


SINUS      FRONTALIS      DEXTER 


ARTERIA     CAROTIS      INTERNA  ARTERIA      CAROTIS      INTERNA 

Fig.  .J?,.      (Head  XVIII.) 
Preparation  showing  relation  of  optie  nerve  to  aeeessory  sinuses  of  the  nose. 


SINUS     FRONTALIS     SINISTER 


SPHENOID 


Fig.  54.     (Head  XIX.) 
Preparation  showing  relation  of  optic  nerve  to  accessory  sinuses  of  the  nose. 


TtlE   srr.C.ICAT.   AXATO.MY   OK   THE    XOSE. 


49 


llic  bnllius.     The  space  bctwcMMi  the  iicivi'  nml  1l Iliinoid  laliyriiitli 

iiuToasos  in  almost  diroct  iiroiioiiioii  as  thr  imiac  aiipi'oaclics  tlio 
litilhus,  and  its  .junrdun  with  IIh'  luilluis  is  ^I'lhTallx  tlic  imsilioii  n[" 
liToatest  distance  betwi'cii  llic  in'rw  ami  lln'  rllnuniil  lali\rintli. 

In  only  one  case,  xii  (Fig.  47)  does  tlic  aiiti  ridi-  iilnnoidal  cell 
come  in  close  relation  with  the  o]i1ic  iici-vc  icplaciiii;'  a  posterior 
ethmoid  cell  wliirh  lies  liclow  it.  The  iflarKni  whirli  tlic  iifrvr  liears 
io   the  last   iinstfi'inr  clliiiiiiid,   wlidi    thai    i-i'll    n'lih-iccs   llic   sphenoid. 


DUCTUi     NASOLACRIMAL 


DUCTUS      NASOLACRIMALIS 


SINUS     SPMENOIOALIS     SINISTER 


CEREDRALIS      AN 


CELLULA 
ETHMOIOALIS 
POSTERIOR 
LAMINA     CRIBROSA 

CEREBRALIS     AN-'ERIOR 


Fig.  no.     (Head  XX.) 
Prciniration  .showing  lolutioii  of  oplie  nerve  to  aecessoi.v  simisos  of  tlie  nose. 


is  very  characteristic.  I'nr  in  tlic  twd  instances  in  wliicli  tliis  re[)lace- 
inent  is  present  in  tin'  heads  (•xainiind.  xvi  {F\'j:.  51)  and  xviii  (Fig. 
53),  the  nerve  is  I'oiind  tu  run  aldu.i;  tlie  external  wall  of  the  cavity. 
This  increases  the  ethmoid  poi-tion  very  considerably,  dianging  it 
from  a  course  along  an  angle  to  one  along  a  wall  which  it  follows 
in  an  almost  surprising  manner.  This  ]ii-obably  exjilains  the  cases  of 
optic  iicnrilis  which  complicate  an  ethmoiditis  without  an  accom])aiiy- 
ing  sphenoiditis,  as  in  the  Avriter's  ca.se  of  l)lindness  cured  by  ethmoid 
exenteration. 


:>() 


(iim;i;a'I'1vf.  snuiEi;^'  oi'  'niK  xosk,  •imikoat.  anh  kai:. 


The  frontal  sinus  is  n'lati\cl>'  dislant  I'l-oiu  tin-  i)|itii'  iin-vr.  the 
nearest  ])oint  Ix'inn-.  as  a  rule,  at  tlic  iiiiifr  side  of  tlic  orhil,  and  hi^re 
it  is  nuich  riirthcr  away  than  tiic  O()rresj)onding  anterior  ethmoid 
cells,  "wliieli  ordinarily  lie  anterior  to  it  at  the  level  of  the  optic  nerve. 
In  some  instances,  however,  the  frontal  sinus  may  extend  for  a  con- 
siderable distance  backward:  for  example  vii.  x,  xi,  xii,  xv.  xvii, 
XVIII,  XX.  In  all  the  cases  the  siinis  is  much  closer  to  the  optic  nerve 
than  where  the  sinus  remains  anterior. 

In  all  the  specimens  the  periorbital  fat  makes  a  close  relation 
with  the  maxillary  sinus  ini|i(issilile,  altliiiii!;ii,  in  some  instances,  the 
distance  is  less  than  10  mm. 

Nasolacrimal  Duct. 

The  increasini;-  disposition  to  treat  stenosis  of  the  nasolacrimal 
duct  by  operation  thrcninh  the  nose  justifies  a  study    of  its  topoii'raphic 


Rifilit  hitoral  wall  of  tlu>  nose  with  pxiiosure  of  the 
and  ilin-tus  iiasnlacrimalis. 


saccus  nasuhu'rinialis 


THE   SURGICAL   .\X.\T(iM\     nv    TlIK    XOSK. 


51 


relations  in  tlio  iioso.  Tin-  superior  and  inferior  canalienltp  lacrimalos, 
wiiicli  start  at  tlio  pnncta  lacrinialis.  convey  the  tears  into  an  expanded 
pdUi-li  railed  the  saeeus  hicriiiialis  closed  ahove  ami  Ix'inn'  continuous 
lielow  witii  the  ductus  nasolacrinialis  wiiich  itsell'  opens  just  below  the 
niaxillar\   attachment  ot"  the  concha  inferioi-. 

Tile    saccus    Incriinnlis   lies    in    the    fossa    laci-ininlis    hetween    the 
crista  lacrinialis  aiiteiini-  and  tlie  crista  lacrinialis  |Misieriiir  (  Kiii's.  !). 


ROTrs      INTERN 


CHIASMA      OPTICUM 


SEPTUM 
SINUUU    - 
SPHENOIOALtU 


FOSSA      MEDIA  - 


TORUS      TU8ARIUS         C 


Fig.   57. 
Coronal  section  tlirougli  the  .sphenoid  sinuses,  leniovitl  of  so|>tiini  sinmini 
sphenoidaliiim  and  exposure  of  the  hypophysis  by  cutting  awn.v  tlic  l>one  of 
tlie  posterior  wall  of  the  left  sphenoid  sinus. 


III.     It  exti'iids  tu  the  canal   icaiialis  nasolacri'iialis  I  and  iner,y:es  into 

the  tluctns  nasolacrinialis  wliidi   runs  lietwcen  the  lateral  wall  of  the 
|«ose  and  the  maxillary  sinus. 
'  The  illustralion    I  Ki-.  ."iCi   slmw,-  tjic  course  of  the  sac   (the  upper 

expaiide.l   |M,rtion)   ,-ii|il   ilic  duct   aloiiir  the  external  wall  of  the  nose. 

Ill    the    speciiiMii,    III,.    Ihum.   1,1    the    external    wall    has    lieen    cut    awav 


52  OI'KRATIVE    SriKiKKV   OF    THE    XOSE,    THROAT,    AND    EAR. 

leaving  tlie  sae  and  (hi'  duct  (roe  as  far  as  its  opciiint;'  i)ol()\v  tlio  in- 
forior  turbinate.  It  is  to  he  observed  that  they  lie  anterior  to  the 
middle  turbinate  and  aiiti'i'ior  and  interior  to  the  lirst  cthiiioid  cell 
which  is  here  exposed. 

Hypophysis  (Pituitary  Body). 

The  location  of  the  jiitnilary  Itody  oi'  hyj)oi)hysis  behind  the  sphe- 
noid sinuses,  makes  it  a  factor  in  intranasal  surgery.  It  lies  in  the  fossa 
hypophyseos  of  the  sphenoid  bone  (Fig.  56).  It  consists  of  an  anterior 
grey  portion,  ectodermic  in  origin,  and  a  posterior  wliite  portion,  epider- 
mic in  origin,  connected  by  the  infnndibnlnm  -with  the  third  ventricle.  A 
reflection  of  the  dura,  diaphragma  sell??,  Avhich  stretches  from  the  an- 
terior to  the  posterior  clinoid  processes  separates  the  hypophysis  from 
the  oi^tic  chiasm  and  optic  tracts,  Avhich  lie  just  above  it.  The  in- 
fundibulum  penetrates  the  dura  beliind  the  optic  chiasm  and  lietweeii 
the  light  and  left  optic  tracts.  Laterally  the  cavernous  sinus  surround- 
ing the  internal  carotid  artery  comes  into  relation  with  the  pituitary 
body  and  the  adjacent  structures.  Anteriorly  and  inferiorly  it  comes 
into  relation  with  the  sphenoidal  sinus,  as  shown  in  Figs.  12  and  56. 
Figure  57  is  an  illustration  of  a  preparation  made  by  ci;tting  away 
that  part  of  the  roof  of  the  sjohenoid  sinus  forming  the  hypophyseal 
fossa  and  the  dural  investment,  leaving  the  pituitary  body  free  in  the 
cavity.  The  septum  Ijetween  the  two  sinuses  has  also  been  removed. 
The  specimen  shows  how  the  hypophysis  may  be  safely  exposed  by  an 
endonasal  oiieration  through  the  sphenoid  sinuses. 

Vascular  Supply. 

Arteries. — The  arteries  of  tlie  external  nose  have  their  origin 
mainly  from  the  arteria  maxillaris  externa.  Branches  of  the  arteria 
oplithalmica  and  arteria  septi  comnmnicate  with  the  network  from  the 
arteria  maxillaris  externa.  The  frontal  I'egion  is  sujiplied  by  the  arteria 
oplithalmica,  the  arteiia  frontalis  and  the  arteria  supraorbitalis. 

The  nasal  cavities  and  the  accessory  cavities  are  supplied  by  the 
branches  of  the  arteria  opldludniica,  arteria  maxillaris  interna  and  the 
arteria  maxillaris  externa. 

The  arteria  sphenopalatina,  terniinal  branch  of  the  arteria  maxil- 
laris interna  passes  from  the  fossa  pterygopalatina  through  the  for- 
amen siihenopalatinum  into  the  nasal  cavity,  giving  off  the  arteriae 
nasales  posteriores  and  the  arteria?  nasales  posteriores  septi  (nasopala- 
tine). 

The  branches  of  these    vessels    supply    the  inferior,  middle  and 


THE   SURr.U'Ar.   AXATOMY    Ol"   THE    XOSK.  53 

superior  turbinate?,  the  mucosa  of  the  iiiferioi'  and  iniiMlc  im-at us.  Ilic 
s))honoi(l  sinus,  and  also  a  i)ortion  of  tlie  si']i1uim. 

Tli(^  arteria  ctliinoiilalis  autt'rioi-  ami  lln'  arlei'ia  ellinioidale 
]iosl(M-ior  leave  lli(>  oiliil  llirou-li  llh'  rinaiiicn  cdiinoidalis  aulerius 
and  the  fciranien  ctlniiDidali'  |iii>tcriu^  i-r-|icc1i vch .  cnlci-  llic  cianial 
cavity  ])assiii<i'  under  tlu'  dura  and  iicirorafc  into  the  nose  lliroui;h  llie 
hiinina  ciilirosa  supjjlyiuj;-  llie  ctlinmid  cells,  and  llic  upper  porlinn  nf 
tlie  lateral  nasal  Avail  and  sepluin. 

The  arteria  alveolaris  superior,  and  aiteria  alveolaris  posierior 
and  the  arteria  infraorhitalis  sn])])ly  llie  mucosa  of  the  niaxillaiy  sinus 
and  the  periosteum  of  tin-  maxilla. 

Veins. — The  veniis  network  of  the  external  noso  is  connected  with 
that  of  tlie  vena  facialis  anterior  and  vena  o]ihthaliuioa,  the  following: 
veins  collectinp:;  the  su])i)ly,  vena  nasofi-outalis  and  vena  auR'ularis. 

The  A-eins  of  the  nasal  cavities  and  the  accessory  cavities  are  c(ni- 
nected  Avith  those  of  the  nasopharynx,  eye,  dura,  Avhile  those  of  llie 
mucosa  of  the  concha  are  connected  willi  1lic  plexus  cavernosus  in  ad<li- 
lion. 

The  A-enons  supply  in  this  ref;i()u  is  collected  by  the  veiui  ethmoid- 
alis  anterior  and  the  vena  ethmoi<hdis  posterior  Avhich  enter  the  A'ena 
ophlhahnica  superior  and  the  vena  (iphtbabnica  iid'erior. 

Innervation. 

The  nerAnis  olfactorius  sends  its  filanieuls  (fila  olfactoria)  about 
twenty  in  number,  thron,£!;h  tin-  lamina  cril)rosa  and  they  sui)])ly  the 
mucosa  of  the  superior  and  middle  upjiei-  pml  of  jlie  furbinale  and  the 
-septum  in  the  correspondiuft-  position. 

The  first  and  second  branches  of  the  iiervus  li-i^eminns  sujiply  the 
nasal  mucosa.  The  iiervus  ellnnoi(hdis  aiilerioi-  ami  nervns  elliinoidalTs 
posterior  ori2:inate  from  llie  lirsl.  and  tlie  nervns  siibeiiop.-d-itinus  and 
uerA'us  infraorbital  from  the  second. 

Tlie  nervus  ethmoidalis  posterior  which  is  accomj)anied  liy  a  small 
branch  from  the  sphenoi)alatine  su])])lies  the  nmcosa  of  the  s])henoid 
sinus  and  posterior  ethmoid  cells.  The  nervus  ethmoidalis  anterior  has 
three  branches,  the  ramus  septi  sui)])lyiii^-  the  ui>i)er  portion  of  the 
mucosa  of  the  septum,  the  ramus  lateralis,  the  middle  turbinate  and 
anterior  portion  of  the  inferior  luiliiiiate  and  ]iosterolateral  wall  of 
the  nose  and  the  ramus  anterioi-  to  that  of  the  anterior  portion  of  the 
roof. 

The  neivns  iurraorl)italis  uives  niT  the  nervi  alveolares  superiores 
which  sn)i]ily  the  mucosa  of  tlie  niaxillarv  sinus  and  anterior  part  of 
llie  lloor  of  llie  nose.     Tile  pjiii::  I  loll  -|ilienii|i;ilalinniii  j;-ives  olV  the  nei-xi 


54  OPEKATIVE   riUKGERV   OF   THE   XOSE,   THROAT,   AXD   EAK. 

iiasales  wliich  supply  the  ujiiht  aiul  posterior  portion  of  the  lateral  wall 
of  the  nose,  the  mucosa  of  the  su})erior  meatus,  and  the  superior  and 
middle  turbinates  and  ethmoid  cells. 

The  nervi  nasopalatini  arc  branches  of  the  gangiicm  sphcnopala- 
tinum  which  supply  the  posterosuperior  portion  of  the  septum.  The 
nervus  nasopalatinus  is  the  largest  branch  of  the  sphenopalatine.  It 
passes  down  the  septum  to  the  canalis  incisivus  and  supplies  the  adja- 
cent portions  of  the  septum. 

The  nervus  ethmoidalis  anterior  supijlies  the  mucosa  of  the  an- 
terior ethmoid  cells  and  frontal  sinus;  the  nervi  alveolares  superiores 
the  maxillary  sinus;  the  nervus  ethmoidalis  posterior  and  the  nervi 
nasales  the  posterior  ethmoid  cells;  and  the  nervi  nasales  the  sphenoid 
sinus. 

Sympathetic  System. — Fibres  fi-oin  the  plexus  caraticus  pass 
through  the  ganglion  sjihcnopalatimnn  which  gives  off  fibres  which  are 
distributed  to  the  posterior  two-lhii-ds  of  the  inferior  and  middle  turbi- 
nate and  nasal  septum. 


(  ii.\|'ti;k  II. 
SIRCICAL  ANATOMY  OF  TIIK  IMIARYNX,  LARYNX.  AND  NKCK. 

P,v  Ckoik;!-.  15.  \V(M,!..  M.|). 

THE  PHARYNX. 

Tlic  ]iliaryiix.  wliicli  is  a  ruiiiicl-sliniH'd  tiilic.  is  divided  for  ooii- 
vpiiience  of  dcsfri])tion  into  lliirc  |i<irliniis.  (lie  iins()])liar\nix,  oro- 
])liarynx  and  tlio  lar>ni.2;opliarynx.  Diiiinu  i|iiift  insjiiinlion  with  tlio 
montli  closed  it  presents  anteriorly  in  (irdcr  I'loiii  nlin\c  dowinvnrd 
the  posterior  nares  or  olioantp,  the  soft  ]ial;itc  willi  i(s  ;iii1ciii)r  pillars 
attaclieil  to  the  tongne  and  its  postciim-  |iillars  to  tlu'  Inlcial  wall  of 
tlie  pharynx,  the  e])i<ilottis  (the  tip  of  wliich  is  almost  in  contact  with 
the  nvnla).  the  laryngeal  openin,e:.  the  posterior  snrface  of  the  aryte- 
noid hoilies.  and  on  cai-li  side  of  these,  the  iiyrifoiin  sinuses.  Each 
lateral  wall  preseiit>  the  Eustachian  in-oiuinence  with  the  oiieiiin?  of 
the  Eustachian  tuhe.  posteiior  to  tliis  the  fossa  of  Kosenmiiller  and  he- 
low,  the  lateral  folds  of  the  ]>liaryn\.  The  posterior  wall  is  a  smooth 
surface  .^howinj;-  small  deposits  of  lymjihoid  tissue  and  is  continuons 
ahove  with  the  vault,  which  arches  forward  to  the  upjier  part  of  the 
(•lioan?(».  Tn  the  vault  is  situated  the  iaruc  mass  of  |yiii|i|ioid  tissue 
which  is  desiu'iiated  the  ]iharyn,u-ea]  toii-il.  Tin'  pliai-yn\  is  f^'reater 
in  its  lateral  than  in  its  anlei-opo-teiini-  diameter,  the  greatest  hreadth 
lieill--  just   aho\e   the  Soft    palate. 

The  Nasopharynx. 

The  nasoiiharynx  exteiidiui;-  from  the  \ault  to  ilie  lowi  i-  horder 
of  the  soft  ])alal('  is  an  open  eavity.  thi'  latei'al.  -npeiaor  and  posterior 
walls  of  which  are  riuid.      The  choana'  oi'  po>tei-ioi-  nai-es  are  two  ohiong- 

siiaces  takin--  the  pla< f  jirael  ieall\-  the   w  hoh'  of  the  anterior  wall. 

The  vault  or  foinix  of  the  pliarxnx  forms  tin'  i-oof  of  the  cavity  and  is 
oeeu])ied  in  part  h\  the  pliaryn;;-eal  tonsil. 

The  Pharyngeal  Tonsil,  composed  of  lymphoid  tissue,  varies  ex- 
tremely in  size  and  shai)e.  Tt  Tiiav  consist  simjjly  of  a  few  small  eleva- 
tions si-;n-cely  notieeahle  to  the  naked  eye,  or  it  may  he  a,  lare:e  pendant 
mass  fillin.i:  tlie  :;reater  jiart   of  the  iiasopharym:-ea]   caxify.     Tn  sha)ie 


5G 


OPKHATIVK    ST'i;(lKi;V    OK    TIIK    XOSK.    'I'llltOAT,    AXD    KAIt 


it  may  be  a  more  or  lesi^  distinct  rounded  elevation,  2)la('ed  directly  in 
tlie  middle  of  tlie  vault  just  behind  the  ii])per  level  of  the  clioanaj  and 
the  upper  iiavt  of  the  nasal  sejjtum,  or  it  may  be  dilTused,  spi-eading 
from  the  vault  out  into  the  fossa  oC  Rosenmiiller,  downward  on  the 
posterior  pharyngeal  wall,  and  latterly  to  the  lateral  folds. 

On  each  side  of  the  jjluu-yngeal  tonsil,  and  at  about  the  level  of 
the  posterior  end  of  the  inferior  lurliiual  is  the  pharyngeal  orifice  of 


Fi"-.  o.S. 


lal 


Median    .soctimi    Uimuyli    face    of    an    adult    man,    sliowing    tin 
relations  of  the  structures  duiing  quiet  nasal  respiration. 

1,  Frontal  sinus;  2,  Anterior  palatal  pillar;  3,  Posteritu-  palatal  ]iLlIar; 
4,  Sphenoid  sinus;  5,  Posterior  edge  of  nasal  septum:  6,  Fossa  of  Koseu- 
niiiller;  7,  Pharjiigeal  tonsil;  8,  Ostium  of  i:iisi.Mlii:Mi  tube;  9,  Dotted  line 
showing  contour  o,f  the  tong-ue;  10,  Salpiiiu(i|ili;ii  \  nyi-al  fold;  11,  Plie^ 
triangularis;  12,  Palatal  tonsil;  13,  Lateial  ].liai'viiL;enl  fold;  14,  Epi- 
glottis;  1."),  Wnfric.ular  liaiid;   16,  'Vocal  c.-onl. 


the  Eustachian  tulie.  The  opening  is  quite  large,  funnel-.sliaped,  with 
a  small  end  of  the  funnel  directed  towards  the  tympanum.  Above  and 
behind  the  opening  is  the  Eustachian  prominence,  consisting  of  a 
roniidcd  ridge   rorm<Ml  liy  the  projection  of  the  Eustachian  cartilage. 


SURGICAL    AX.VTOMY    (ll"    Tl  1 K    rilAKVNK.    l.AItVNX.    ANTI    NKCK.  •)  i 

The  anterior  inari^in  of  (lie  ojii'iiin^-  is  niiirli  less  ])r()iiiiiii'nl  lli;iii  (lio 
poslerior  ami  tins  fact  helps  f;reatly  in  llir  iiilroihu'tiou  nl'  llir  En- 
slacliian  catheter.  Kxleiuliui;-  dowinvard  froiii  tlie  ]ios(erior  iiiarR-iii 
of  tlie  Eustachian  lube  is  a  folil  of  niucons  nicnil)rane,  llie  sal])iii,2:o- 
pharyiiiical  fdlil.  wliicli  is  ;;-ra(lually  lost  in  Ww  lalcral  wall  of  llif 
pharynx,  or  it  may  i)e  cuutiiuious  with  tin'  lateral  ])harynj;('al  I'ohl.  A 
somewhat  similar  riilfte,  but  much  less  marked,  is  the  sa]pi]i,c;opalatine 
fold  which  runs  from  the  anterior  bordcM"  of  the  Eustacliiaii  orifico 
dowinvard  and  forward  tn  ilii'  jialatf.     ( 'out  rarlion  of  llir  Icvatur  |ialati 


-  8 
—  S) 
~   10 

11 


•t 


Fi" 


Modian  sertion  tliroutih  tlie  fare  of  ;in  infant  one  niontli  oM,  showing' 
the  relations  of  the  stnietures  duiinij  quiet  nasal  respiration. 

1,  Superior  turliinate;  2,  Middle  turbinate;  .S,  Inferior  turliiuate;  4, 
.\nterior  palatal  pillar;  5,  Body  of  sphenoid  l)one;  6,  Eustachian  tube; 
7,  Pliarvufjeal  tonsil;  K,  Posterior  jjulatal  pillar;  ft,  Dotted  line  showing 
rontour  of  the  tongue;  10,  Plica  triangularis;  11,  Kpiglottis;  12,  Ventricular 
band:    in.  Vocal  cord. 


iiniscle  produces  an  elevation  known  as  1lii'  Icx.itor  cushidii  which 
]iresses  to  a  greater  or  less  extent  a.i;ainst  llic  lower  border  of  the 
pjustaehian  oritiee.  Behind  the  Eustacliiaii  ]ironiiiience  is  a  wedcce- 
shaped  depression  called  the  fossa  of  TJoseimiiillcr,  or  the  lateral  recess 
of  the  pharynx.  This  depression  jiiadually  disappears  on  the  lateral 
wall  of  the  pharynx  at  about  the  level  cif  the  soft  palate.  It  tends  to 
accentuate  the  Eustachian  inoiiiiiieiu-e  riinl  the  salpinsojiharynKeal 
fold.  In  the  middle  of  the  vaiill  nf  IIh'  |iliaiyiix  is  a  sinus  runnin,2:  up 
behind  the  pharynfreal  tonsil.  Tlii^  hiius  i-  ciilled  the  bursa  pharyn.irea, 
aixl  is  supliii^ed   hy  some  to  111',  tlie  reiiiiiillll    of  the  lower  poi-lion  of  the 


58 


opEiiATivK  srncr.nv  of  tiik  xosk,  tiu'.oat,  Axn  kak. 


])oucli  of  lf;itlik(\     II  is.  how cxcr,  simply  an  oi-i-liisioii  sinus  foruKMl  by 
llii'  aiilicsioii  of  folds  ol'  (lie  ]iliar\';i,i;('al  tonsil. 

'i'lio  vault  of  lln'  |iliai'\'nx  rcccixcs  its  hlooil  supjily  cIiicHy  from 
the  pliaryuR'eal  In-ancli  ol'  tlic  xidian  art('i->.  Tlic  liranclics  of  tliis 
arlei'y  aua.'^toiiiose  with  tlio  ascending;'  |)liaryuf;('al,  and  tlie  ])liaryi>goal 
))rancli  of  the  pteryf^opahitiiie.  "^I'hc  pt(M-y<;-opalatine  is  a  branch  of  tlie 
internal  maxillary,  wliile  the  aseendiiii;-  ]iliaryng-eal  comes  directly  from 
tlie  external  carotid.  Tlie  veins  follow  louglily  the  course  of  their  cor- 
responding arteries  and  o]K'n  into  the  ])teryg'oid  plexus  Avhich  is  situ- 
ated partly  on  the  inner  surface  of  tlic  internal  pterygoid  muscle,  and 


Fin'.  00. 

Transverse  section  Uirough  the  head  of  a  eliild  one  muiitli  old,  just 
in  front  of  the  posterior  phar\-ngeaJ  wall.  The  neck  has  been  twisted  so 
that  the  lar^-nx  is  thrown  somewhat  to  tho  left.  Illustration  sliows  the  rela- 
tion  of  the  epislotlis  to  the  uvula. 

1,  l'h;nvni;c;il  tonsil;  12.  Xasal  septum;  :'.,  Uvula;  4,  Epiglottis;  .",, 
Trache;i. 


partly  around  the  external  pterygoid  muscle.  The  pterygoid  plexus 
empties  posteriorly  into  the  internal  maxillary  vein  and  anteriorly  into 
the  deep  facial  vein. 

The  lymphatic  drainage  of  the  vault  oL'  the  ])harynx  is  tluough  a 
rather  close  mesh  of  lymijh  vessels,  which  drain  either  into  the  retro- 
pharyngeal lymph  gland,  or  into  the  posterior  or  external  group  of  the 
deep  lateral  chain,  the  vess(>ls  passing  posteriorly  to  the  large  vessels 
of  the  neck,  and  behind  the  rectus  capitis  anticus  muscle. 

The  nerve  supply  of  the  pharyngeal  vault  is  derived  fi-om  the 
pharyngeal  branches  of  jVIeckel's  ganglion. 


SL'lU;ir.\L    AXATO.MV    (i|-    TIIK    rilAllVNX,    I.AliVXX,    AND    NIX'K.  .>:' 

The  Oropharynx. 

Tlio  division  licfwccii  the  nasoiiliarynx  and  ompliarv  n\  is  a  vory 
movahlo  oiio  roiisistinp;  of  tlio  free  edge  of  tlip  soft  jialali'.  The  upper 
siirfaco  of  Iho  soft  ])alafo  foniis  an  antoroinfovior  wall  to  tho  iiaso- 
]ihar>iix.  mIhIc  llic  iid'ciiin'  siii  I'ari'  is  diroctod  towards  llic  moutli.  Tii 
tho  iid'aiit  llio  lowtM-  liordci-  of  tlio  soft  palato  roachos  almost  to  tlie 
o]ii.£;lottis,  l)\it  in  llic  adiiK  tlicro  is  nioro  spaco  betwooii  the  epic:lot1is 
and  the  ])alate  Avliich  is  filled  in  l)y  the  dorsum  of  the  tongue.  The  an- 
terior wall  of  th(>  oroiiharynx  is.  tlierel'ore.  made  \\p  of  the  uvula,  jiha- 
rynneal  ]iortion  of  the  dorsiun  of  the  lontiue  and  the  eiuirlottis.  The 
lateral  diameter  is  about  twiee  the  anlerojiosterior  <liameter,  l)ut  both 
of  these  distances  aii'  coiistaiilly  diaiiuiun',  aceordin.u,'  to  the  action  of 
the  palatal  and  ])haryiif;-cal  mnscles.  The  lateral  wall  of  the  oro- 
pharynx generally  presents  a  more  or  less  nuirked  perpendicular  ridiye 
1)1'  lyiii]iIioid  tissue,  sometimes  siidlcen  of  as  the  latei-al  ])liaryn,n'eal  fold. 

Palatal  or  Faucial  Tonsil.  The  ])alalal  tonsil,  more  .cjenerally 
s))oken  of  as  the  faucial  but  less  coirectly  so,  is  situated  in  a  fos.«a  be- 
tween the  anterior  and  i^osterior  palatal  or  faucial  ])illars.  Both  in 
size  and  shape,  the  tonsil  varies  extraordinarily.  To  understand  this 
variation  we  must  study  the  develo])ment  of  the  orj2,an.  Probably  the 
lirst  recognizable  sif^-n  of  the  faucial  lonsil  is  to  be  found  in  the  embryo 
at  four  months.  .\t  five  months  fliere  is  a  distinct  vertical  .c:roove 
about  2  mm.  in  lieiiilif.  at  tlie  Itolloni  of  wliicli  a  small  mass  of  adenoid 
tissue  has  already  develoju'd  and  in  this  mass  minnte  slit-like  impres- 
sions can  be  found.  In  the  embryo  at  eifiht  nionflis  the  form  of  the 
tonsil  is  fairly  constant.  At  this  time  the  tonsil  does  not  ])ro,ject  be- 
yond the  surface  and  is  covered  anteriorly  by  a  fold  called  the  plica 
trianf;'ularis  oi-  operenlum.  This  i'ohl  divides  a  little  above  its  middle 
into  two  distinct  liraiiche.-.  one  inniiim;-  anti'riorly  to  the  foimui^  form- 
in,U"  a  fold  called  the  plica  ]ii-etonsillai'is,  and  anolhei-  I'unnini^  poste- 
I'iorly  passing-  round  tlie  base  of  the  tonsil  an.lage  called  the  iilica  iiifra- 
tonsillaris.  The  space  bonnde<l  by  tlie.se  two  folds  above,  and  by  the 
tongue  below,  is  called  the  fossa  triangnlaris.  The  u])per  part 
of  the  plica  triangularis  is  continued  above  the  tonsil  until  it 
meets  the  |ios1eiioi-  pillar  of  ihe  fauces  and  in  this  position  is 
called  the  ]ilica  suji:  alonsillaiis.  .\\  this  time  fiie  tonsillar  mass 
is  iri'egularl>'  di\ided  into  three  lobes  by  two  lissui'cs,  running 
from  Ijolow  and  behind  ui)ward  aii<l  I'oiward.  'i'lie  lower  and  middle 
are  merged  into  one  another  in  IVont  an<l  the  upiier  and  middle  less  dis- 
tinctly so  l)ehind.  At  the  Junction  of  the  two  lower  the  ])lica  triangu- 
laris becomes  adherent  to  the  tonsillar  mass,  and  in  this  wav  a  recess 


60 


ori'.IIATIVK    SrUdKKV    Ol'    TIIK    XOSK,    TIIIIOAT,    AM)    KAR. 


is  roi'iiied  above  and  slii;liUy  to  tlic  rioiit  of  llic  supci'ior  convolution 
which  later  develops  into  the  sii]ii  atousillar  Fossa.  Jn  tlie  majority  of 
children  a(  hirlh  this  ty])ical  condition  can  be  recognized  oidy  with 
difficulty,  as  the  tonsil  is  already  beginning  to  take  on  the  irregularity 
of  growth  which  is  one  ol'  its  characteristic  features.  After  birtli  the 
dovelo])nienl  of  the  tt)nsil  is  very  irregular,  and  its  linal  shape  and  size 
de])end  upon  the  position  and  anioind  of  adenoid  tissue  present.     In 


Fi-.  ci. 
Tlic  reyion  (if  the  p;iliital  tuiisil. 
1,  Supratonsillaa-  fossa;  2,  Uvula;  3,  Posterior  palatal  pillar;  4,  Ejii- 
glottis;  5,  Plica  supratonsillaris;  6,  Dotted  line  showing  the  subsurface  extent 
of  tlie  tonsil ;  7,  Anterior  palatal  pillar  made  prominent  by  traction  on 
the  tongue;  S,  Plica  triangularis;  9,  Cut  surface  of  tongue,  traction  being 
made  downward. 


the  majority  of  cases  the  greatest  amount  of  development  takes  jjlace 
in  the  lower  two  lobes.  These  by  tlieir  growth  project  ontward  and 
finally  hide  from  view  the  superior  lobe  which  can  be  found  only  by 
looking  deep  into  the  supratonsillar  fossa.  If  the  adenoid  tissue  de- 
velops in  the  supratonsillar  margin,  a  distinct  tonsillar  mass  will  be 
found  in  the  palate,  and  its  groA\th  downward  leaves  a  fistulous  tract 
running  upward  from  the  hihim  of  the  tonsil.     The  plica  triangularis 


srr.ciiAi.  .\^"A•^nM^•  m'  -nii;  i'ii\i;vnx.  I..\l;^  nx.  anh  ni:ci<.  til 

iiKiy  remain  ruiliiiicnlarx  in  wliicli  case  it  can  scarcely  lie  seen,  oi"  it 
may  dexclop  so  as  lo  cdvci'  to  a  urt-aler  oi-  less  exieiil  llic  anterior 
lH)rlioii  oL"  tlio  loiisilh'.r  mass.  In  those  cases  in  wiiicii  the  (ie\H'loj)nient 
involves  chiefly  the  snperior  lohe  the  su]tratonsiUar  fossa  becomes  al- 
most obliterated.  'I'lie  vn,<;ai'ios  of  tlie  .i;'ro\vtli  of  adenoid  tissue  in  the 
various  ])arts  of  the  tonsil  determine  the  sliajie  and  size  of  the  tonsillar 
mass. 

'file  Idiisil  is  separated  from  the  snrroundini;-  structui'es  by  a  dis- 
tinct tilirous  ca])snle.  This  capsule  surrounds  the  tonsil  on  all  sides 
except  the  mesial  free  surface.  At  the  front  it  runs  inward  beneath  the 
l)lica  triangularis  over  the  surface  of  the  tonsil  almo>t  to  the  line  where 
the  plica  merges  into  the  tonsillar  mass.  Behind  it  terminates  at  the 
fxee  edge  of  the  posterior  pillars,  above  it  reaches  to  the  supratonsillar 
margin,  but  below  it  does  not  come  quite  to  the  surface  epitlieliuni,  as 
lliei'c  is  \-ery  a]it  to  l)e  a  thick  lymphoid  deposit  Just  below  tiie  tonsil. 
'Phe  ca]isule  sends  strong  librous  tral)ecid;e  into  the  sulistance  of  the 
tonsil  which  carry  the  blood  vessels,  lymphatics  and  nerves.  An  im- 
])ortant  peculiarity  of  the  operculum  or  ])lica  triangularis  is  that  in  the 
fully  developed  tonsil  it  is  attached  firmly  to  tlie  tonsillar  mass  only 
close  to  its  very  edge,  and  can  be  readily  separated  from  the  capsule 
which  covers  the  front  of  the  tonsil. 

The  crypts  are  ingrowths  of  the  surface  epithelium,  their  lumina 
l)eing  formed  by  the  desquamation  of  a  central  core.  These  crjq^ts  vary 
Itoth  in  number  ami  in  size  but  they  generally  run  deep  into  the  ade- 
noid mass,  terminating  usually  clo.«e  to  tlie  capsule,  and  they  may  com- 
municate more  or  less  with  each  other.  They  are  as  a  rule  larger  and 
more  numerous  in  the  up])er  part  of  the  tonsil.  In  the  usual  type  of 
tonsil  the  growtli  of  the  two  lower  lobes  forms  a  deep  pocket  close  to 
the  cai)sule.  with  its  opening  in  the  supratonsillar  fossa.  This  pocket 
is  not  in  the  true  sense  of  the  word  a  ci\  pt.  hut  is  rather  an  inclusion 
recess  similar  to  that  which  I'oinis  in  the  ]inlate  from  overgrowth  of 
the  supratonsillar  margin. 

The  tonsil  is  surrounded  exteinally  hy  the  |iliar_\  ngeal  ajtoneu- 
rosis  which  is  rather  loosely  associated  with  the  capsule.  Ex- 
ternal to  this  is  the  superior  constrictor  nniscle  of  the  pharynx.  Still 
further  externally  is  the  bucco])haryngeal  fascia,  a  thin  and  in  jilaces 
ill  defined  layer  which  surrounds  the  constrictors  of  the  ]iharynx  and 
the  outer  surface  of  the  buccinator  muscle,  hnmediatdy  beyond  tliis 
rather  thin  covering,  the  tonsil  is  in  relation  \\  itli  a  space  tilled  with 
loose  Fatty  areolar  tissue.  The  outer  wall  of  this  space  is  formed  by 
the  internal  pterygoid  muscle;  its  posterior  wall  by  the  prevertebral 
muscles  ami  the  internal  wall  by  the  pharynx.     This  triangular  space 


G2 


OI'KIIATIVE    snuiEKY    Ol'   THE    XOSE,    THROAT,    AXl)    EAl!. 


is  iiTegTilavly  dividi'd  into  two  snuillcr  8])a('es  by  tlie  stylopliaryiigens 
jnusc'le,  and  extenial  1o  lliis  l)y  tlic  styloglossus  iiinsde.  The  faucial 
tonsil  is  in  relation  ^vitll  tlic  anterior  of  tlicse  two  divisions,  Avliile  the 
internal  earolid  artei-y  is  placed  well  hack  in  llic  ])osterior  division. 
The  intei'uai  earolid  is  never  closer  than  1.5  cm.  IVoni  the  Avail  and 
the  pharynx  is  more  or  h'ss  separated  from  il  hy  the  interposition  of 
the  stylopharyngens  nmscle.  The  external  caidtid  artery  lies  about  2 
cm.  from  the  iatei-al  Avail  of  the  pharynx,  and  has  interposed  between 
it  and  the  tonsil  a  ])orlion  of  the  jiarotid  gland,  and  llie  Avhole  of  the 


Fitc.  (52. 
Dissection  of  tlio  rpi;i()ii  of  the  |Kilatal  toifsil  from  the  outside. 
1,  Capsule  of  palatal  tonsil;  2,  Facial  aj'terv;  3,  Hypoglossal  nerve; 
■i,  Superior  thyroid  artery;  5,  Tonsillar  Inaueh  of  facial  .artery;  tj.  Occipital 
artery;  7,  Internal  carotid  artery;  S,  Liiig^ial  artery;  9,  External  carotid 
artery;  10,  Spinal  accessory  nerve;  11,  Conunon  ciirotid  artery;  12,  De- 
seeudens  hypoglossi  nerve ;   13,  Pneumogastric  nerve. 


musculature  of  the  styhiid  ])rocess.  Tl  must  be  remembered,  however, 
that  the  outer  surface  of  an  enlarged  and  embcthh'd  tonsil  is  not  in 
the  same  plane  as  the  pharyngeal  wall,  and  it  thus  may  come  in  much 
closer  relation  to  the  large  blood  ves.sels  in  the  neck  than  the  above 
description  would  lead  one  to  suppose.  Furthermore,  the  facial  artery 
quite  frequently,  after  branching  from  the  external  carotid,  has  a  de- 
cided upward  bend  before  it  SAveeps  outward  to  pass  ai'ound  the  ramus 
of  the  jaw.  AVhen  this  upper  bending  is  marked,  the  loop  of  the  artery 
thus  formed  conies  in  close  relation  to  the  inferior  porticm  of  the  t(Ui- 


SfndlCAI.    AXATOMV    OK    Tl  1 K    niAKVW.    I.AIIVNX.    AND    NKCK.  iV-') 

sil,  iiiakiiiL;-  it  ]i(issil)l(>  tn  wouikI  this  artery  diiriiii;-  iipcratimis  mi  tlic 
tonsils.  Tli(^  only  nnisclo  iiitorvoninir  bchvocn  it  and  llic  tonsil  is  tlio 
superior  coiisf riclor.  Tlie  two  carotid  arlorics.  liowovor,  arc  separated 
from  the  tonsil  liy  llic  stylopliaryniiciis  and  (lie  slyloc^lossus. 

Till"  Mood  sujiply  of  (111'  tonsil  comes  cliielly  tlirnuft-li  tlie  tonsillar 
liranrli  of  tln'  I'afial  arter\.  The  lower  jiarl  ol'  tlie  tonsil,  however, 
may  he  sni)])]ied  from  a  hranch  of  the  lin;;ual,  sometimes  cominf?  from 
the  dorsalis  liniiiia'.  and  sonielimes  from  the  main  linirnal  trunk.  Oc- 
casionally the  iialaline  liranch  of  the  asciMidin.n'  ])haryn^eal  sn])plies 
the  posterior  n])per  ])art.  "^Phe  internal  maxillary  also  contrihules  to 
the  hlood  sn]i]ily  of  the  tonsil  thronnh  a  small  hranch  comin<t-  from  the 
])Osterior  or  descending'  palatine,  '^i'he  division  from  the  facial  jyener- 
ally  breaks  \ip  into  two  or  three  branches  which  penetrate  the  capsule 
and  which  a.cain  break  \\]^  into  numerous  lu-ancln's  before  enterinir  tlie 
tonsil  with  tlie  traberiila'.  Sometimes  almost  a  jilexiis  of  arteries  is 
formed  in  the  outer  layers  of  the  capsnh'  hy  tlie  anastomoses  of  the 
supplyin,c'  blood  vessels. 

The  nerve  supply  of  the  tonsil  is  tlirou<;h  a  special  branch  of  the 
jilosso])liaryns('al.  which,  unitinii'  with  branches  from  the  iiharyneeal 
])lexns  forms  what  mi,i;ht  be  called  a  small  lonsillar  ])lex\is. 

Pillars  and  Lateral  and  Posterior  Walls.  The  anterior  ])alatal 
pillar  or  anterior  pillar  of  tlie  lauces  is  a  I'oM  caused  by  the  prom- 
inence of  the  palatoglossal  muscle,  wliile  the  ]iosterior  pala- 
tal pillar,  or  ]iosterior  pillar  of  the  i'aiices,  is  forniwl  by  the 
palatopliarynf;eal  muscle.  r>e]iiii(l  the  p<isteii(ir  palatal  ])illars  on 
each  side  of  the  pharynx  is  found  a  more  or  less  well-marked  mass  of 
lymphoid  tissue.  Imiuitudinal  in  sliaiu',  s'e'K''"*".^'  spoken  of  as  the 
lateral  fold  of  the  ]iharyn\.  This  lon<;itudinal  elevation  appears  to  be 
a  continuance  dnwiiwaid  of  tli<'  salpini;-opharynfi-eal  fold,  its  promi- 
nence, however,  i-  due  not  to  a  inomineut  muscle  l)ut  to  the  lymphoid 
tissue,  which  necordiuf?  to  Cortes  at  times  resembles  the  structures  of 
the  faucial  tonsil.  j)ossessing-  ciyjits  and  other  of  its  ]>eculiar  histolo.cie 
characteristics.  On  the  po.'Jterior  i)haiyii,L;-eal  wall  we  fmd  a  varyiiij; 
number  of  isolated  patclies  of  lymphoid  tissue,  spoken  of  as  lymi)hoid 
follicles,  n'hese  small  lymiihoid  structures  are  more  numerous  in  the 
uppei'  ]iai't  of  th(>  thi'oat.  and  seem  to  lie  an  irree-ular  downwai'd  ex- 
tension of  the  pharyn^^eal  tonsil. 

The  Laryngopharynx. 

The  laryiiueal  portion  ol'  the  jiliarynx,  oi'  the  laryii,i;dpharynx.  ex- 
fends  fi'oin  the  epiglottis  down  behiinl  the  larynx  lo  the  level  of  the 
sixth  cervical  vertebra.     This  corresponds  about  to  the  lower  liorder 


64  (iPKHATivK  sn;i;Ei;Y  of  the  nose,  tiikoat,  and  ear. 

of  ilio  cricoid  cartiliigf.  Below  tlie  arytenoid  cartilages  the  walls  of 
tlie  laryngopliarynx  are  in  apposition  except  during  the  act  of  swal- 
lowing. In  'front  of  the  epiglottis  and  on  the  base  of  the  tongue  is  an 
accumulation  of  hanplioid  tissue  called  the  lingual  tonsil.  The  varia- 
tion in  size  and  shape  of  the  lingual  tonsil  is  very  marked.  Generally 
it  is  scarcely  more  than  a  rather  close  aggregation  of  separate  nodes, 
giving  simply  a  roughened  appearance  to  the  base  of  the  tongue.  Some- 
times, however,  it  develops  in  two  lateral  masses  which  may  be  so  large 
as  to  be  more  or  less  pendulous. 

Below  the  lingual  tonsil  there  are  two  depressions,  the  bottom  of 
which  represents  the  junction  of  the  epiglottic  nuicous  membrane  with 
that  of  the  tongue.  These  depressions  are  called  vallecula?.  The  val- 
leculse  are  separated  by  a  distinct  fold  of  mucous  membrane,  the  median 
glossoepiglottic  fold,  or  as  it  is  sometimes  called  the  frenuin  of  the  epi- 
glottis. Each  is  bounded  externally  by  another  fold  of  mucous  mem- 
brane, the  lateral  glossoepiglottic  fold. 

The  ijyriform  sinuses  are  deep  depressions  somewhat  boat-shaped, 
elongated  in  a  vertical  direction,  placed  on  each  side  of  the  u^sper  part 
of  the  larynx  between  the  ala  of  the  thyroid  cartilage  and  tlie  thyro- 
hyoid membrane  on  the  outside,  and  the  arytenoepiglottic  fold  on  the 
inside.  Tliey  are  bounded  anteriorly  by  the  lateral  glossoepiglottic 
folds,  and  posteriorly^  l^ass  gradually  down  into  the  laryngopharjmx. 

Tlie  blood  su])i)ly  of  the  laryiigopharynx  is  derixcd  soli  ly  from  the 
external  carotid,  and  chiefly  through  the  ascending  pharyngeal 
branch.  Other  contributory  branches  are  the  ascending  palatine  branch 
of  the  facial,  and  the  tonsillar  branch  of  the  facial,  also  the  posterior 
palatine  and  pterygopalatine  branches  of  the  internal  maxillary,  and 
sometimes  a  few  twigs  from  the  lingual.  The  smaller  veins  from  the 
])harynx  pass  into  a  pharyngeal  plexus  Avliich  may  be  found  between 
the  buccopharyngeal  aponeurosis  and  the  constrictors.  This  plexus 
anastomoses  with ,  the  ptoiygoid  plexus  above,  and  empties  below 
either  into  the  internal  jugular  or  into  the  facial  vein. 

Lymphatics  of  the  Pharynx. 

The  lymphatics  of  the  pharynx  consist  of  a  netW'Ork  beneath  the 
]iharyngeal  epithelium  and  the  superficial  layer  of  the  mucous  cutis. 
This  network  is  probably  most  marked  on  the  posterior  surface  of  the 
larynx  and  in  the  pyriform  sinuses;  it  is  also  very  rich  in  the  phalan- 
geal tonsil  but  very  scanty  near  the  esophageal  opening.  A  less  im- 
portant network  is  found  in  the  muscular  tissue. 

The  superior  collecting  trunks  generally  pass  first  to  the  retro- 
])liaryngeal  lym|)h  glands.     They  may,  however,  pass  by  these  glands 


SlTvCICAL    AXATOMV    Ol'    TIIK    rilAltVNX,    I.AIiVNX.    ANU    NECK.  05 

and  liTiiiiiiatc  in  1  iic  ilrc|'  ccrN  iral  1\  iii|i|iat  ics,  ;iiiil  ari'iirdiiiii-  (o  I'oirrr, 
into  the  anterior  ■ir(iu|i,  luit  aceonliuii-  {a  the  irscaiclK's  of  tlic  autluir, 
botl)  anatomic  and  clinii-al,  tlicy  tcrminali'  In  the  ixistcrior  u:ron|). 

Tlie  middle  enlleeiiim-  truid<s  drain  tlie  niuenus  nieniliraiie  ol'  tlic 
tonsillar  roj;ion.  These  vessels  jierl'orati'  the  ninscular  enat  jnsl  al)ovt' 
the  fjreat  conm  of  the  hyoid  bono,  and  tenninati'  in  ihe  anterior  f>lands 
of  the  interna]  jniiidar  li'ron]!  near  the  iiosterior  lieily  of  the  di.u'astrii- 
niusele. 

The  inferior  rulleetinu  trnuks  ilraiii  the  Inwcr  part  of  the  ))har>n\ 
ninnin.i;'  nndei-  the  ninenu-  nieinhrane,  and  tenil  to  e(mvers-e  in  the 
]iyrifonn  siinises.  'i'hey  here  iiniie  wiili  the  snjjerioi'  lyni]ilmties  of 
the  larynx  and  with  them  end  in  tin'  ,i;lands  of  the  internal  jugular 
lironj)  just  Ix'low  the  diuastrie  mnscle. 

The  lymph  vessels  of  the  soft  jialate  are  very  nnmoroiis,  forming- 
a  fine  network  which  is  more  or  less  continuous  with  that  of  the  neiiih- 
boring  stiiietnres.  This  network  is  richest  in  the  \ivnla.  There  are 
separate  colleetinii:  trunks  from  the  su]ieiioi-  and  iid'erior  surfaces  ami 
from  the  fancial  pillars.  The  colleetinij'  trunks  from  the  superior  sur- 
face are  more  or  less  nnited  with  the  collectors  from  the  nasal  fossa> 
which  may  be  divided  into  asiendinii  trunks  and  descendiin;'  trunks. 
The  former  pass  aronn<l  the  pharynx  and  terminate  in  the  retroi)haryn- 
geal  lymph  glands;  the  otheis  ])ass  down  tlirongh  the  ])osterior  inllars 
and  terminate  in  the  internal  jugnlar  glands  near  the  digastric  muscle. 
The  collecting  trunks  from  the  inferior  surface  run  downward  through 
the  anterior  ]iillars  and  joining  the  collcelors  fVoni  the  vault  of  the 
l)alate  terminate  in  llie  internal  .iuLiniai'  ulaiid>  ni'ar  the  diuastric 
muscle.  The  co'deetor-  of  ilic  anterior  pillar  unite  with  those  from  the 
inferior  surface,  anil  the  I'ollcetors  from  the  postei'ior  pillar  with  the 
descending  trunks  of  the  superior  surface.  Occasionally  scnne  of  the 
lymphatic  vessels  from  the  po>terioi-  pillars  terminate  in  the  glands 
of  the  intt'rnal  Jugular  griuip  as  high  up  as  the  hifurcaticm  of  the 
carotids. 

Nerves  of  the  Pharynx. 

The  nerves  ol'  the  pharynx,  hoth  inotoi-  and  sensory,  come  mainly 
from  the  })haryngeal  plexus.  This  I'lexus  which  lies  just  beiu'ath  the 
mucous  mend)rane  is  forniecl  hy  hrain'hes  from  the  glossopharyngeal, 
from  the  pnc'Uino:;asli-ic  and  from  the  -nperioi-  cervical  ganglion  of 
the  s.vmpathi'tic.  The  pharyngeal  hraiu'li  of  the  pneumogastric  is 
really  derived  from  the  accessoiy  p<irlion  ol'  the  s|nnal  aecessor.v.  The 
fancial  t<in-il  receives  a  branch  directly  from  the  glossopharyngeal, 
while  the  suri-ounding  region  and  the  .-oil   palate  are  supplied  by  the 


G6  ()i'Ei;.\ri\K  sii;(;i:i;v  (ir  the  \ose,  tiiiioat.  axm  ear. 

jiostcridf  mill  ('\t('i-ii;il  iinl.'iliuc  liraiiclics  i>\'  Meckel's  .lian.iiliiMi.  'I'lic 
\m\\{  lif  till'  pliarxiix  and  the  slrucfnn's  ardiiiid  llic  orilicc  of  llic  l']u- 
stac'liiaii  lulic  arc  su|i|ilic(i  l>y  the  |iliaryngeal  braiicli  of  Meckel's 
siaiiii'lioii.  Tile  nmedus  iiKiiiliraiic  nn  the  external  posterior  wall  of 
llie  larynx  is  supiilicd  \)y  the  superior  lar\'n,i;'eal  ner\'e. 

The  Structure  of  the  Pharyngeal  Wall. 

Surrounding'  the  nineons  membrane  of  the  pharynx  is  a  distinct 
layer  of  connective  tissue,  the  pharyngeal  a]ioneurosis.  This  fascia 
xai'ii's  in  thickness  being  usually  strongest  wliere  the  nnisi-ular  wall  of 
Ihi'  jiharynx  is  weakest;  and  it  gradually  thins  out  as  the  lower  end 
of  tlie  ])h;irynx  is  approached.  Abo\e  it  blends  with  the  ])eriosteum 
at  the  base  of  the  skull,  and  is  attached  to  the  Kustacliian  tubes,  the 
margins  of  the  posterior  iiares  and  to  other  jiortious  of  the  skull  from 
which  the  pharyngeal  constrictors  arise.  At  the  sinuses  of  Morgagni, 
that  creseentic  space  betAveen  the  base  of  the  skull  and  the  uiiper  bor- 
der of  the  superior  constrictor,  the  fascia  is  very  strongly  developed. 
Externally,  the  pharyngeal  aponeurosis  is  intimately  associated  with 
the  constrictors,  and  forms  the  capsule  of  the  faucial  tonsil. 

The  muscular  wall  of  the  pharynx  is  made  u])  of  two  strata,  the 
internal  or  circular  layer  consisting  of  the  three  consti'ictors,  and  an 
external,  or  more  jjrojierly  longitudinal  layer,  consisting  of  fibres 
from  the  sty!oi)haryngeus  and  from  the  palatopharyngeus  muscles. 
The  three  con.strictor  nuiscles  appear  as  modified  cones,  the  middle 
overlapiMng  the  superior,  and  the  inferior  overlapping  the  middle. 

The  Superior  Constrictor  Muscle  arises  from  the  lowei-  half  of  the 
posterior  border  of  the  internal  plei-ygoid  plate,  below  this  fioni  the 
ptei'ygomandibular  ligament  and  from  the  internal  surface  of  the  man- 
dible just  back  of  the  last  molar  tooth.  Tt  is  also  attached  antei-ioiiy  to 
the  mucous  membrane  of  the  floor  of  the  mouth.  The  u])per  libei-s  of  the 
muscle  curve  u])war(l  and  are  inseilcd  into  the  jiharyngeal  spine  of 
the  occipital  hone.  This  arching  of  the  u])|>er  tihers  forms  a  creseentic 
interval  in  the  pharyngeal  wail  called  the  sinus  of  .Moigagni.  Thi-ongh 
this  opening  pass  the  Eustachian  tube  and  the  levator  and  tensor  ])alati 
muscles.  The  middle  and  inferior  hbres  of  the  supeiior  constrictor 
j)ass  posteriorly,  radiating  upward  and  (h)wnwar(l  to  be  inserted  into 
the  median  rai)he  on  the  posterior  wall  of  the  ]ihai'ynx.  Tlie  lower 
iihi-es  are  oA-erla])ped  by  the  middle  constrictoi'. 

The  Middle  Constrictor  Muscle,  somewhat  smaller  than  the  su])e- 
rioi',  arises  fi'om  the  stylohyoid  ligaments  and  from  both  tlu>  small 
and  great  coi-nua  of  the  hyoid  Itone.  Its  lihres,  radiating  u])war(l  and 
downwai'd,  ])ass  ])osteri()rly  to  be   inserteil   into  the   median   I'aphe  of 


Srr.CHAI.    AN'ATOMV    111-     llll'.    I'll  \m  NX.    I.Ai:\NX.    ANIl    XKCK.  (u 

Ilic  |iliar\ii\.  The  lower  liluo  iuc  ox cil.-iiiiK'tl  hv  llir  u|i|ic'i-  lilin'^  ol' 
tlic  iiil'ci'inr.  'I'lir  iiilriiial  lai\\iii;i'al  ar1iT>  ami  in'ivi'  pass  llii-nimli 
the  iiitci-\al  liclwiTii  the  sii|iciii)r  and  niitlillc  coiislrictoi-s. 

'IMic  Inferior  Constrictor  Muscle  aiiscs  fniiii  tlic  obli(|iu'  liiif  dl'  the 
tliyroiil  (.•artilayc  and  I'ldiii  the  sides  nf  tlic  cricoid,  lis  lilircs  radiat- 
iu.ii'  mostly  upward,  pass  poslciiorly  to  lie  inserted  into  the  median 
pharyiisjeal  raphe.  The  lower  lilucs  Mend  with  the  musculature  of 
the  uitpor  cm]  of  llie  csophauns.  At  I  lie  lower  cdi^e  of  flu"  muscle  the 
exIiTiial  laryimc'il  artery  and  iicivccome  iuln  relation  with  the  larynx. 

The  longitudinal  muscular  lihi'es  of  the  pharynx  are  m.-nle  up  of 
(wo  distinct  nnisch's.  the  jialatopharyn.n-eus  and  the  slylo|iliaryiif;-<'Us. 

The  PalatopharjTlgeus  Muscle  fornis  tlu'  posterior  laucial  pillai-. 
It  is  composed  of  two  la\<'rs.  a  lliiii  posl<'rior  siiperioi-  sheet  spread- 
iiifi'  tlirouiih  the  suhstaiicc  of  the  soft  ])alate.  aiicl  a  thicker  aiiteroiii 
ferior  laver  which  arises  from  the  jiostei'ior  hor<ler  of  the  hard  jialate. 
Those  two  layers  ))artiall.\'  en\clop  the  a'/.N.^os  n\nhe  and  levat<n- 
palati  niusck's.  They  unite  at  the  lowci-  edi^c  of  the  soft  palate  where 
tlioy  reeoivo  additional  lihres  from  the  lOustadiian  tuhe  and  passiu.u: 
downward,  spri'ad  ont  in  a  thin  slu'ct  in  the  wall  of  tlie  pharyu.x.  The 
posterior  tihres.  under  cover  of  the  middle  and  inl'erior  <'onstrictors, 
are  inserted  into  the  apoueurosi.s  of  the  pharynx  and  s(une  I1l)res 
decussate  with  those  of  its  fellow  of  the  o))i)osite  side.  The  anterior 
lihres  ;ire  inserted  into  the  iHisterior  horder  of  the  thvroid  cai-tilanc 
and  anteriorly  nieriic  into  the  stylopliaryimi'iis. 

The  Stylopharyngeus  Muscle  arises  from  the  hase  of  the  styloid 
jiroeess.  Passim^  downward  ami  forward  l)etween  the  two  carotid  ar- 
teries it  jjenetrates  the  iiharym^i  al  wall  hetwt'cn  llie  sn|ierior  and  middle 
coiisti'ictors.  Tt  is  inserted  hy  a  hroad  hase  into  tlie  superior  and  poste- 
I'ior  hordi^r  of  the  tliyroiil  cartilai^c.  its  lihres  ln-iiii:  heie  continuous 
with  the  palatoithai'yugeus.  It  is  also  iuserteil  into  lln'  pharyuiieal 
aponeurosis. 

The  soft  jtalate  and  uvula  max  he  <'onsidere(l  as  (he  anterior  wall 
of  the  l)liarynx.  Tliev  are  maile  up  of  a  mu-cular  \'nU\  covered  hy  niu- 
eous  uuMuhrane. 

The  uuiscles  which  ccMistitiile  the  soil  palate  consist  of  lix'e  pairs 
— the  |inlatophar>  nueus  (already  de>crilied|,  the  palatoylossns,  the 
azyii'os  n\nhe.  the  lexator  palali  and  'he  tensor  palati. 

The  Palatoglossus  Muscle  is  |ilaced  directly  heiieatli  the  mucous 
niemhrane  of  the  ton.iriu-.  the  anti'i'ior  palatal  pillai'.  and  the  anterior 
surface  of  the  palate.  It  is  a  thin  sheet  of  mu.scular  lihres  which  arise 
from  the  under  surface  of  the  soft  palate,  some  of  its  lihi-es  hlendimi 
with  those  of  its  fellow  of  the  opposite,  and  passes  downward  to  form 


68 


orEiiATivE  sn;GEi;v  of  the  xose,  tiikoat,  and  eai; 


the  anterior  pillar  of  the  fauces.  It  is  iiisei'led  info  the  sides  of  the 
tong'ue,  ami  lilciuls  Avitl  .lie  stj'loglossns  and  (lcc|i  iransv crsc  lil)rcs  of 
the  toiiaiie. 

The  Azygos  Uvulae  Muscle  is  rdimd  ln'tweeii  llu-  layers  of  the 
l)alatoi)har\n,ii,eus  and  arises  from  the  posterior  nasal  spine  and  the 
aponeurosis  of  the  soft  palate.  The  two  narrow  hundles  unite  as  they 
proceed  downward  to  tlie  tip  of  the  n^■nla. 


tensor   ]>ahiti    ami    tlie   lo\atiir 
;■  tlie   soft   palate   to  be  drawn 


Fig.   ()?.. 

Dissectiou  showing-  tlie  relation  of  tin 
palati  muscles.  The  leva,tor  is  eut  jierniitti 
forward. 

1,  Eustachian  cartilage ;  2,  Tensor  palati  muscle ;  3,  Levator  palati 
muscle ;  4,  Hamular  process ;  5,  Internal  pterygoid  muscle ;  6,  Middle 
constrictor  of  pharynx;  7,  Posterior  palatal  pillar;  S,  Sphenoid  sinus;  9, 
Middle  turbinate;  10,  Inferior  turbinate;  11,  Tendon  of  tensor  palati  mus- 
cle: 12,  Insertion  of  levator  palati  muscle;  13,  Cut  edge  of  velum  palati;  14, 
Palatal  tonsil;   15,  Section  of  tongue. 


The  Levator  Palati  Muscle  arises  from  the  inferior  surface  of  the 
apex  of  the  petrous  bone  close  to  the  carotid  canal.  Its  fibres  forming 
a  rounded  belly,  run  parallel  to  and  in  close  ap]iroximation  with  the 
under  surface  of  the  p]ustachian  tube,  to  which,  however,  it  is  not  at- 
tached.   It  is  inserted  in  a  radiating  manner  into  the  soft  palate  beloAV 


SlT.CHAl.    ANATHMV    OF    ■I'llK    rilAKVW.    I.AIIVNX.    AM)    XECK.  Oi' 

till'  o.stiuiii  of  the  tulic.  Till'  arlion  of  this  iiiusclr  mi  tlir  Mustarliian 
tube  is  not  exactly  inuli'istiKid.  'flic  contnu'tioii  nf  tlic  imisclc  by  iii- 
uroasiiig"  its  fircMiiiifcicih't'  tcmls  to  raise  tbc  floor  ol'  tlir  tube  wliicli, 
by  deoroasiiii:'  the  |pci-i)(inliriilai-  width  of  ihi'  liinnMi  nf  the  tube,  iii- 
croasos  tlic  horizontal,  and  this  prohaMy  iiK'i'cascs  the  |iatu!iMii'y  of 
tho  tube. 

Tlu'  Tensor  Palati  Muscle  is  the  n-al  alxbictor  or  dilator  tiil>a'.  It 
arises  in  part  from  the  scaiihoii]  fossa  of  the  internal  pterynoid  jilatc 
and  the  alar  spine  of  tho  s])lu'noid  bune,  anil  in  part  from  the  miter  sur- 
face, or  the  hook-like  border  of  the  cartilauinons  wall,  and  the  meinbran- 
ous  part  of  the  lOustaobian  cartilajie.  liiinnin;;-  downward  so  as  to  form 
an  acute  anji'le  with  the  cartiL-miiious  jiortimi  of  the  tube,  tlie  inuselo 
descends  between  the  internal  ]iter>  L;oid  mn>elr  and  the  internal  jitery- 
H'oid  plate.  It  terminates  by  a  rounded  ti'iidon  which  jiasses  around 
the  hook  of  tlie  lianiular  process  and  is  inserted  beneatli  the  levator 
jialati  into  the  posterior  border  of  the  Iiard  jialate,  as  well  as  the  ajio- 
neurosis  of  the  soft  ]ialate.  The  action  of  this  muscle,  by  iiuHino,-  on 
the  cartila.uinous  hook  of  the  Eustachian  tnbi'.  tend<  to  sliuiitly  imfoM 
it,  which  action  increases  the  lumen  of  the  tube. 

The  nerve  supply  to  the  miisenlature  of  the  phar.vnx  is  chieHy 
through  the  spinal  accessory  by  wa\  of  the  iiharynncal  plexus.  This 
jilexus  supplies  the  constrictors  of  tiie  pharynx,  the  palato,ij;lossus,  the 
jialatoiiharyngeus,  the  azyuos  uvula-,  and  the  levator  jpalati.  The  ten- 
sor palati  is  supplied  from  the  otic  si:an.itlioii.  the  st.\  lojiharynv'i'us  by 
the  glossopharyngeal  nerve,  and  the  inferior  constrictors  receive 
branches  from  the  vagus  through  the  external  and  recurrent  laryngeal 
nerves. 

THE  LARYNX. 

'I'lie  larynx  should  be  looked  npmi  a>  I  lie  upper  part  of  the  trachea, 
especially  modified  for  the  production  of  the  \iiice  smind.  Us  con- 
struction is  such  as  to  permit  the  instant  ai)pro.\imation  and  ad.just- 
ment  of  two  elastic  ))ands,  tln'  \oeal  emds.  These  may  lie  thrown  into 
the  recpiired  vibrations  by  a  column  of  air  I'oreed  up  thmn-li  the  tra- 
chea. To  accomplish  this  juirpose  numerous  Joints,  li-ameiits  and 
muscles  are  necessary.  By  reason  of  the  beant\  and  perfection  of  the 
••irrangement  of  these  A-arious  structures  the  lar>  n\  is  one  of  the  most 
interesting  organs  of  the  body  to  the  aiialmnist.  It  is  situated  in  the 
median  line  of  tln'  nec|<  just  in  IVmil  of  the  esophagus,  and  is  very 
lo(>se|\-  attached  to  the  snrrmmding  slriictnres.  On  each  side  poste- 
riorly are  the  large  vessels  of  the  neck,  and  above  arc  the  hyoid  bone 
and  tongue. 


70  orKiiATix  T.  si-i;i;ki;v  ny  tiik  xose.  tiii'.oat,  and  eak. 

'I'lic  iii1('i-i(ii-  III'  llic  larynx  opens  into  the  iowi-r  jioi-tion  of  tlio 
plinr^iix  jnsf  lim-k  nf  ami  helow  tlic  base  of  tlii'  ton,i;iU'.  Tin-  aditiis 
laryngis  is  oliliqucly  ])laoL'(l  facing  upward  and  hackward.  It  is  boi-- 
dorod  above  li>  the  epiglottis,  on  each  side  liy  the  arytonoepiglottic 
folds,  and  ]josteriorly  by  the  mucons  nienibrane  covering,  the  cavti 
lages  of  "Wrisberg  (cnneifonn  cartilages)  and  of  Santoi'ini  (cornicnla 
Iai-\-ngis).  These  cartilages  surmount  the  ai-ytciioid  i-artilages  and 
follow  their  niovenieiitp,. 

The  interior  of  the  larynx  is  divided  into  three  ])arts  by  the  false 
and  true  vocal  cords  (\-entricular  and  ^■0l•al  bands). 

Superior  Division. 

Tlie  superior  division  of  the  larynge;d  cavity  is  compressed  later- 
ally where  the  ventricular  Itands  oi-  false  cords  separate  it  from  the 
middle  division.  The  anterior  wall  is  formed  in  greater  part  by  the  pos- 
terior surface  of  the  epiglottis.  The  upper  part  of  the  posterior  sur- 
face of  the  epiglottis  is  concave  except  the  tip  which  is  turned  slightly 
forward.  Below,  the  epiglottis  shows  a  distinct  swelling,  the  cushion 
of  the  epiglottis.  This  swelling  corresponds  in  position  to  the  thyro- 
epiglottic ligament.  The  lateral  walls  are  smooth  except  for  two  slight 
vertical  elevations,  the  anterior  being  due  to  the  cuneiform  cartilage 
and  the  ]iosterior  to  the  anterior  margin  of  the  arytenoid  cartilage  and 
the  cartilage  of  Santorini.  The  shallow  grove  between  these  eleva- 
tions is  called  the  philtrum  ventriculi  of  Merkel.  The  anterior  of 
these  elevations  runs  to  the  posterior  end  of  the  false  vocal  cords  while 
the  posterior  passes  doAvnward  to  the  true  cords.  The  narrow  pos- 
terior wall  is  formed  by  the  interarytenoid  fold  and  varies  in  breadth 
according  to  the  degree  of  ai)proximation  of  the  arytenoid  cartilages. 

The  Ventricular  Bands,  or  false  cords,  form  a  partial  floor  of  the 
superior  division  of  the  larynx.  In  front  they  arise  from  the  angle 
between  the  two  wings  of  the  thyroid  cartilage,  and  they  reach  back- 
ward oid\  to  the  swelling  on  the  h\teral  wall  caused  by  the  cuneiform 
cartilages.  They  are  never  in  apposition  and  they  never  ol)scure  the 
margin  of  the  true  vocal  cords  from  view.  The  chief  su^tport  of  this 
fold  of  mucous  membrane  is  the  thin  superior  thyroarytenoid  ligament 
and  a  few  muscle  fibres.  The  distance  in  the  adult  male  larynx  from 
the  ventricular  band  to  the  summit  of  the  arytenoid  cartilages  is  about 
one-half  inch  and  to  the  ti]i  of  the  epiglottis  one  and  a  half  inches. 

Middle  Division. 

The  middle  division  of  the  larynx  is  limited  abo\e  by  the  false 
cords  and  below  bv  the  true.     On  each  side  and  covered  bv  the  ven- 


>;ri;(;icAi,  axatomy  hk   thk  i'iiaiivxx,  i.aiivnx,  axu  xkck.  71 

triciilnr  liamls  i~  ilu'  lai->  im'i';il  ^imis  (u-  xciitriflr  nl  Mdiu.ivni.  Its 
oavity  is  sdiiicwlint  Inriici-  tliaii  its  (iix'niii';  and  it  rcaclii-s  I'lnni  tin'  an 
fiTJor  aiiiilo  ot'  the  ahr  of  the  lliyroiil  cartilaiii'  liai-k  to  the  anlcridr 
liordcr  of  tlic  arytenoid  caitilaiie.  Tliis  vontriflo  of  ^ror.i!;a.u:iii  is  ox- 
tiviiu'ly  xarialilc  liolli  in  sliapc  and  size.  It  may  ronsist  simply  of  a 
sijiiiK'  liroa<l  |iockct  fxtcndini;  u]'\\ard  liftwi'i-n  ihr  xciilriciiiar  liaud 
and  tile  ala  of  tlic  tliyi'oid  cartila.iir  oi-  it  ma\  lie  a  lii'aiifliod  striictiii'o 
with  a  \aryiim  nnmhor  of  terminal  ci-ypts.  Occasionally  tliiTc  exists 
a  sliort  branch  diri'ctcd  downward  from  the  main  jiockct.  Tiie  walls 
of  the  sinus  contain  i|uilc  a  hir.iic  dcjiosit  of  lymi)hoi(l  tissue  and  fre- 
(luently  if  not  always  dclinite  nerminatint;-  follicles  are  ])resent  so  that 
the  whole  structure  is  very  similar  to  a  larye  tonsillar  crypt.  Thi' 
upward  extension  ol'  ili<'  sinus  is  i|uitc  counnouly  sjioken  of  as  the 
laryngeal  saccule  and  it  does  not  usually  extend  njiwanl  beyond  the 
border  of  the  thyroid  cartilasi;e,  thoiiii:h  in  rare  instances  it  may  rer.ch 
to  the  ])Osterior  part  of  the  hyoid  bone. 

The  True  Vocal  Cords  are  shorter  Init  incu-e  |prominenl  than  the 
false  and  extend  from  the  angle  formeil  by  the  ahv  of  the  thyroid  to 
the  vocal  jjrocesses  of  the  arytenoid  cartilaiies.  Tn  cross  section  the 
cord  is  jirismatie  with  tlu'  fice  edge  jiointing  upward,  as  well  as  to- 
ward the  median  line.  In  front,  the  <'ords  meet  and  form  the  anterior 
commissure.  Posteriorly,  they  end  at  the  vocal  processes  of  the  aryt- 
enoid cartilages,  but  tbeii-  surface  liiH's  aie  continued  over  the  median 
side  of  the  arytenoid  cartilages,  joining  ]iosteriorly  to  form  the  ])oste- 
rior  commissure.  The  tine  coril>  with  the  oi)ening  between  them  con- 
stitute the  true  glottis,  or  linia  Lzlottidis  which  is  liciierally  designatc'l 
the  glottis. 

Inferior  Division. 

Tin-  infei-ior  division  of  the  larynx  is  somewhat  llalti'Ued  laterally 
above  and  lielow  wliei-e  its  walls  slope  outward  and  downward  from 
the  \'ocal  c(jid~.  Its  walls  are  in  greater  jiait  made  up  liy  tlie  inui^r 
surface  of  the  cricothyroid  ligament. 

Cartilages  of  the  Larynx. 

The  Cricoid  Cartilage  is  the  lowest  and  is  placed  directly  on  toji 
of  the  trachea.  It  is  shaiied  sonii'W  hat  like  a  siiiUct  ring,  witii  the  signet 
part  or  posterior  lamina  ])ro.jectin-  from  thr  nppei-  side  and  the  ui)i)er 
edge  slo])ing  rather  gradually  downward  and  forward  to  form  the  ante- 
rior circle.  The  ring  is  circular  below  cori'espoudiug  to  tiu'  shape  of  the 
trachea,  but  above  it  is  somewhat  laterally  compressed.  On  top  of  the 
posterior  lamina  are  two  oval  convex  facets  which  look  sonu'what  out- 


I'J.  OPERATIVE   srR(;EHV   OV  THE   KOSE,   THROAT,   AXD   EAR. 

ward  as  well  as  \i]>\\  ani.  They  are  the  articiilatiui'-  surl'aces  for  the  aiyt- 
eiioid  cartilages  and  arc  sei)arated  l)y  a  faint  median  notch.  On  the 
iwsterior  surface  are  two  de])ressed  ai'eas  for  the  attachnieiif  of  the 
posterior  cricoarytenoid  mnsck's.  On  tlie  jiostcrior  jiarl  nf  tlic  lateral 
surface  of  the  cricoid,  a  vertical  ridi>e  runs  do\vii\var<l  tVdiii  the  ai'vte- 
noid  articulation.  On  (his  ridge,  just  above  the  lower  border  of  the 
cartilage,  is  a  circnlai-  facet  for  articulation  with  the  inferior  horn  of 
the  thyroid  cai'tilage.    The  inner  surface  of  the  cricoid  is  snionth. 

The  Arytenoid  Cartilages,  two  in  nund)ei',  are  perched  on  the  ante- 
rior part  of  tht'  summit  of  the  jiosterior  lamina  of  the  cricoid.  They 
are  irregularly  i)yramidal  in  shape  and  have  three  surfaces  and  a  base. 
When  the  cartilages  are  in  position  for  phonation  one  surface  faces 
directly  toward  the  median  line,  another  posteriorly  and  the  third  out- 
ward and  fonvard.  The  posterior  and  anteroexternal  surfaces  are 
somewhat  concave,  slightly  triangular,  narrowed  vertically  and  fairly 
even.  A  small  sesamoid  cartilage  is  frerpiently  found  invested  by  the 
])ei-ich(>ndrinm  on  the  external  border  of  the  arytenoid  cartilage.  The 
apex  is  directed  upward,  but  is  curved  sliglitly  inward  and  backward. 
There  are  two  important  processes,  one  the  external  inferior  angle 
called  the  processus  muscularis,  and  the  other  the  anterior  inferior 
angle  called  the  processus  vocalis. 

The  Thyroid  Cartilage  makes  up  tlu"  greater  part  of  the  frame- 
work of  the  larynx.  It  consists  essentially  of  two  large  alfe  joined  to- 
getlier  in  front,  but  separated  posteriorly  liy  the  interposition  of  the 
posterior  lamina  of  the  cricoid  and  of  the  two  arytenoid  cartilages. 
The  anterior  junction  involves  only  the  lower  two-thirds  of  the  whole 
height  of  the  ate,  leaving  a  well-marked  notch  in  the  median  line.  At 
the  bottom  of  this  notch,  the  thyroid  cartilage  forms  the  most  anterior 
portion  of  the  larynx,  and  the  ]irorainence  due  to  its  projection  is 
called  the  pomum  Adami.  There  is  great  variation  in  the  angle  of  the 
junction  of  the  two  cartilages.  In  infants  it  is  more  of  a  curve  than  an 
angle,  while  the  average  for  the  adult  male  is  about  90°  and  for  the  adult 
female  almost  120°.  The  superior  border  of  the  ala  is  convex  ripward, 
while  the  lower  border  is  almost  straight.  Tlie  posterior  free  edge 
of  each  ala  is  prolonged  upward  almost  to  the  hyoid  bone,  foiin- 
ing  the  superior  cornu  and  downward  to  the  articulation  facet  on 
the  side  of  the  cricoid  forming  the  inferior  cornu.  On  the  exter- 
nal surface  of  each  ala  somewhat  posterior  to  its  middle  is  a 
ridge  I'unning  diagonally  from  above,  behind,  downward  and  fonvard. 
It  is  usually  spoken  of  as  the  oblique  line  and  begins  above  at  a  prom- 
inence just  below  the  su])erior  border  of  the  ala  called  the  sujierior 


SriUlU'AI,    AXAIOMV    (IK     IIIK    1'1IA1:VNX.    I.AKVXX.    AN'D    N'Kl'K.  !■« 

tuliiTrlc.     It  I'lids  (111  llic  iiil'i'riiii-  liiirtkT  in  ;ni(itlicr  indnrniciicc  i-allcd 
llic  inrcrior  tulicrclc 

Till'  Epiglottic  Cartilag'e  is  a  tliin  lamina  '>\'  yWnw  d.-ivtic  r.-nil 
hiiiv  sliapfd  sdnicwliat  like  a  lirdad  and  s\ar|ic(l  paddli'.  willi  it>  liaiidl- 
lu'low  toriuiiiatiii.i;-  in  liir  -Iimii^-  tliyroi'iii.iiltittif  liuanidil.  Its  surfac'c 
is  irroiiulavly  iudoiitcd  li>  di|iri'ssioiis  and  tlunv  arc  niinnToiis  iiorfo- 
rations  ruiinin.u-  throiii-li  tlio  cartilaiic  Its  upper  end  is  I'lcc.  risini: 
just  l)oirnul  the  l)aso  of  the  ton.i;ut\ 

Tlie  Lesser  Cartilages  df  the  lar>n\  arc  six  in  nunilicr.  Tlie  two 
i-artilaniiH's  tiitiroa'  arc  small  nodules  situated  Just  aliove  tla-  suiiorior 
cornu  of  the  thyroid  cartilajie  in  the  lateral  thyrohyoid  liuaniciit.  The 
eartila.n'os  of  Saiitoriiii  or  the  cornicnlatc  cartilaucs,  two  in  iimiilier, 
are  jierched  on  the  apices  (it  the  ai>tcnoid  caitilaL^cs  and  arc  enclosed 
in  the  iiosterior  jiart  of  the  aryteiuH'pi.ylottic  I'dld  of  imicous  iiieinhraiie. 
hi  this  same  fokl,  iinmetliately  external  tn  the  .artilaucs  of  Saiitorini, 
ai-e  the  eartilages  of  Wrisheru'  or  the  euiieiform  caitihuics.  They  are 
ineonstant  structures  hut  ueiierally  iiresent. 

Articulations  and  Ligaments  of  the  Larynx. 

The  ]aryii,<;eal  joints  with  their  lii;amcnts  form  one  of  the  iiidr-t 
interesting  anatomic  features  of  the  larynx. 

Joints. — The  cricothyroid  joints  are  diarthiddial  witji  a  pivotal 
and  also  a  gliding  movement.  The  circular  facets  on  the  internal  sur- 
face of  the  inferior  conm  of  the  thyi-oid  cartilage  are  boimd  fast  l>y  a 
caiisnlar  ligament  to  the  corresixuidiiig  slightly  elevated  circular  facets 
on  the  sides  of  the  cricoid  eartila-c.  The  pdsteiidr  part  of  the  capsular 
ligament  is  strengthened  hy  a  ligaineiitdus  tliickeiiini;'.  The  cricoaryte- 
noid joints  are  more  comiilicatcd  hut  are  also  diartlii-ddial.  They,  too, 
pos.sess  a  pivotal  movemeut  as  well  as  a  lateral  glidiii;^-  iiiiilidii,  and.  ac- 
ccirding  to  some  aiithdrities,  a  slight  aiiterdpdsterinr  rdckiiig  motion. 
'i'lie  ai-ticniar  facet  of  the  cricoitl  is  convex  while  that  of  the  arytenoid 
is  cdncaxc.  Both  articular  surfaces  are  elli|)tical  and  they  never  accu- 
rately coincide  with  one  another.  Tlici-e  is  a  distinct  capsular  ligament 
which  is  strengthened  jiosteriorly  liy  a  prominent  liand,  which  limits 
the  anterior  rocking  motion  or  dis])lacement  of  the  ar\  teiioid  cartilage. 
The  lateral  gliding  motion  of  this  joint,  permits  tiie  two  arvteiioid  car- 
tilages to  ajiproach  one  a  not  her  or  s(  |i;ir,iie.  tlnis  closing  or  opening  the 
jiosterior  third  of  the  glottic  chink-.  'I'lie  jiiNdtal  luoxemeiit  allows  the 
vocal  process  to  move  toward  or  awa\  from  the  median  line  causing 
adduction  or  aliduction  of  tlie  \iic;d  cords. 

There  are  Iwu  importanl    nicmliranes  in   the  l,-ii\  ii\.  ilie  ericothy- 


74  OPEKATIVE    SX'lUiEKY    OF    THE    XOSE,    THItOAT,    AND    EAR. 

roid  and  tlic  tliyroliyoid.  Those  lie  in  the  iiitefvals  between  the  eai'ti- 
lages  as  their  names  desii^nate. 

The  Cricothyroid  Membrane  is  an  important  structure  and  con- 
sists of  three  poilidns;  two  hiteral  divisions  and  a  central.  These  di- 
visions are  all  attached  below  to  the  upper  border  of  the  arch  of  the 
cricoid  eartilaije.  Their  u])per  attachments,  however,  are  very  dif- 
ferent. Tile  central  iiortion  whicli  is  somewhat  trian,i>'ular  in  shape, 
is  strong,  tense,  and  elastic.  The  base  is  attached  to  the  upi)er  border 
of  the  anterior  part  of  the  cricoid  arch  and  the  narrowed  top  to  the 
lower  border  of  the  thyroid  cartilage.  The  latei'al  portions  form  the 
side  walls  of  the  subglottic  juirt  of  the  larynx  ;uid  aic  lined  internally 
only  with  mucous  membrane.  They  arise  below  from  the  upper  border 
of  the  cricoid  cartilage  and  passing  internally  to  the  alas  of  the  thyroid 
find  their  upper  termination  in  the  whole  of  the  length  of  the  inferior 
thyroarytenoid  ligaments,  the  supporting  band  of  the  true  cords.  In 
front,  the  thyrohyoid  membrane  is  also  attached  to  the  inner  surface 
of  the  thyroid  alae  near  the  notch,  and  behind  to  the  vocal  processes  of 
the  arytenoid  cartilages.  The  lateral  erieoarytenoid  and  thyroaryte- 
noid muscles  lie  directly  on  the  outer  surface  of  the  lateral  i)art  of 
the  cricothyroid  membrane. 

The  Tliyrohyoid  Membrane  is  attached  along  the  up])er  liorder  of 
the  thyroid  cartilage  ami  to  the  internal  surface  of  the  hyoid  bone.  Its 
central  or  anterior  itortion  is  thick  and  elastic  and  forms  the  median 
thyrohyoid  ligament.  This  ligament  is  attached  below  to  the  thyroid 
notch  and  above  to  the  upper  margin  of  the  posterior  surface  of  the 
hyoid  bone.  Where  the  ligament  passes  behind  the  bone  a  bursa  is 
generally  found  separating  the  two.  Posteriorly  the  hyoid  membrane 
terminates  in  a  strong  cord-like  ligament:  the  lateral  thyrohyoid  liga- 
ment. This  ligament  runs  from  the  tip  of  the  great  cornu  of  the  hyoid 
bone  to  the  extremity  of  the  su]>erior  cornu  of  the  thyroid  cartilage. 
It  contains  the  small  cartilago  triticea.  The  inner  surface  of  the  thyro- 
hyoid membrane  is  covered  by  the  mucous  membrane  of  the  pharynx, 
while  the  epiglottis  is  sei)arated  from  tlie  median  thyrohyoid  ligament 
by  a  cushion  of  fat. 

There  are  two  thyroarytenoid  ligaments,  the  inferior  and  sujjo- 
rior. 

The  Inferior  Thyroarytenoid  Ligament  is  really  the  thick'ened  up- 
per border  of  the  lateral  parts  of  the  cricothyroid  membrane.  It  is 
the  supporting  ligament  of  the  true  vocal  cords  and  is  attached  ante- 
riorly to  the  njiddle  of  the  thyroid  angle  close  to  its  fellow,  while  pos- 
teriorly it  blends  with  the  vocal  process  of  the  arytenoid  cartilage. 


sim;ii1(  Ai.  AXATdMV  HI"    iiu'.  l'll\I;^^■\■.  I.Al;^^•^■.  wn   niu'K.  i.i 

'I'liis  liu.-inii'iil  roiilaiiis  muiirnnis  yellow  riastic  liiurs  and  mhucI  lim^ 
iH'ai-  it-  anlcrini-  mil  a  small  ikkIuIc  ot"  I'lastio  cartilas'e. 

Till'  Superior  Thyroarytenoid  Lis^ament  is  a  iiiurli  li'Ss  imiMn  lani 
structui'i>  anil  wliilr  tliiiiin'i-  ami  Wfakcr  is  lnnL;r|-  lliaii  llir  inriTini-. 
Il  suiipnrts  llii'  M'litiiiMilai-  liaiiil>.     II  is  allarlu'il  antiM-iurly  In  tin-  lli\ 

I'niil    anulc    .jll>l    aliiiNr    lilr    inl'i'l-inl-    ami    liiis1i'|-in|-|\     tn    a    -mall    I  IiIhTi-Ii' 

oil  the  anterior  sui-l'ai'i'  of  tlif  ai\\  ti'imiil  Jnst  aluivr  llir  proeessus  vo- 
calis.  There  are  a  iVw  rlastir  lilni's  in  it  Init  it  is  miistl\  mniposetl  of 
librons  tissue,  whieh  is  mnri'  nr  li'-s  rnnlinuuus  willi  ihr  sn|i|iiirtim;- 
lihres  of  tlie  ai-ytcnociiiulnttir  I'lijil. 

Ligaments  of  the  Epiglottis.  'I'ln-  cirmlottis  is  fasteiicil  to  the 
l)0(ly  of  the  hyoiil  Imni'  Ky  an  inr-ular  lnnail  rla-tic  haml,  tlir  liyoi-pi- 
sirlottic  lis^'auient.     Fnnn  ihr  inl'i'iior  nannwi-il  mil  of  thf  rpinlnttis  a 


Fig.  (i4. 

The  Ijitoial  pxtenial  surface  of  tl\o  laivnx. 

1.  Siiperioi'  coinu  of  thyroid;  2,  Posterior  lamina  of  cricoid;  ."?,  Inferior 
ciirnu  of  thvroid;  4,  Strenfrthening  band  of  capsular  lifjament;  5,  First 
rin^'  of  the  trachea;  fi,  Alii  of  thyroid;  7,  Superior  tubercle  of  thyroid;  8, 
Olilique  line  of  thyroid;  !),  Centiiil  part  of  cricothyroid  membrane;  10, 
Oblique  portion  of  cricothyroid  mu.scle;  11,  Horizontal  portion  of  the  crico- 
thyroid muscle. 

strong'  thick  lii-anient,  eoniijoscil  nl'  clastic  tissue,  the  thyroejii.nlottie 
linaiiieiit,  runs  to  the  jiosterior  surface  nf  the  tliyroid  anu'le  just  below 
llie  note]].  Besides  tliese  twu  trnc  li.iiauiciits  the  ei)i.nloltis  is  fastened 
to  tlie  tongiie  by  three  folds  uj'  imicous  ineinbraue.  tlie  median  and  two 
i;iti'ial  irlossoepi.L:!nitic  I'ulds.     These  have  already   been  described. 


The  Muscles  of  the  Larynx. 

rmliT  this  brad   will   be  i loci'i bed  iiniy   thnse  muscle-  which  li;ive 
)tli  llieir  urinin  and  insertiim  in  sniiie  part  of  tiie  larvnx  itself.     While 


76  opETiATivE  srr.r.EnY  of  the  nose,  tmhoat,  aicd  ear. 

some  III'  tliriii  arc  coutaincd  entirely  within  the  cavity  Ixumdcd  by  the 
ala  nt'  tiie  thyroid,  tiic  cricdthyioid,  the  arytenoid  and  tlic  |i(istci-ior 
cricoarytenoid  aic  on  the  external  surface  of  the  larynx  ]iro|)er. 

The  Cricothyroid  Muscle  arises  from  the  anterior  surface  of  the 
cricoid  arch  and  the  lower  adjoining  border  and  radiating  upward  and 
backward  usually  sei^arates  more  or  less  distinctly  into  two  divisions. 
The  anterior  of  these  divisions  crosses  the  cricothyroid  interval  more 
perpendicularly  than  the  i)osterior  and  is  inserted  into  the  lower  edge 
and  the  neighboring  inner  surface  of  the  ala  of  the  thyroid.    The  pos- 


Fig.  (i.j. 
The  muscles  of  the  hxryngeal  wall  on  the  posterior  aspect. 
1,  Arytenoepiglottic  muscle;  2,  Cartilage  of  Santorini;  3,  Aryteuoideus 
oliliquus  muscle;  4,  Arvtenoideus  transversus  muscle;  5,  Cricoarytcuui.leus 
posticus  muscle;  (5,  Epiglottis;  7,  Retroliyoicl  bursa;  8,  Thyrohyoid  muscle; 
9.  Thyroepiglottic  muscle;  10,  Thyroid  cartilage;  11,  ThyroarA-tenoideus 
muscle;  12,  Cricoarytenoideus  lateralis  muscle;  13,  Articular  facet  for 
inferior  cornua  of  thyroid;  14,  Cricoid  cartilage. 

terior  division  is  inserted  into  the  anterior  aspect  of  the  inferior  cornu 
of  the  thyroid.  The  cricothyroid  is  sometimes  rather  closely  asso- 
ciated with  the  inferior  constrictor  of  tlie  pharynx. 

The  Posterior  Cricoarytenoid  Muscle  arises  by  a  broad  base  from 
a  depression  which  covers  almost  the  entire  half  of  the  posterior  sur- 
face of  the  cricoid  lamina.  Its  fibres,  converging  as  they  ascend  in  a 
slightly  latei-al  direction,  are  inserted  into  the  posterior  surface  of 
the  muscular  ])idcess  of  the  arytenoid. 

The  Arytenoid  Muscle  consists  of  two  parts,  a  superficial  oblique 
laver  and  a  deep  transverse  layer. 


sri;i;icAT.  axaiomy  di'    iiii:  riiAinxx.  i.akvnx.  axu  nkck.  ii 

The  oliliiiui'  •■irvlriioid  is  a  iiairrd  iiuisclc.  one  imisdc  ci-ossiiisj:  tlie 
ollioi'  ill  tlio  median  liin'  nn  ilic  iMiNtciinr  aspect  df  tiir  larynx.  I'^ael: 
iniisele  consists  ol'  a  narinw  Ijiindli'  wliieli  arises  rrmii  liie  jKisterior 
side  of  the  imiseiilar  jM-oeess  ol'  liie  arvteimid  and,  nniniim-  nl)li(|U('ly 
ujnvanl,  passes  arnniiij  the  outer  side  i<\'  the  summit  nl'  tlu'  ojijiosito 
arytenoid  ear1ihi,i;e.  Sun f  the  lilues  are  here  inserted  intd  the  aryt- 
enoid hut  uian>'  ciintiuue  upwaiil  iutu  the  arytenoepij;"h)ttie  fold,  as 
tlie  aryteniiepii;hittie  muside.  and  are  juined  neai'  tlie  c^pi.u'lottis  V)y 
lihres  IVuni  the  th\  ine|iii:liilt  ie  nnisch'. 

'I'lie  traus\ersi>  aryleiniid  i.-  a  lraus\'erse  sheet  of  muscle  Iteneatli 
the  oblique,  stretching  heiween  the  posterior  aspect  of  the  outer  bor- 
der of  each,  arytenoid  cartih-iu'e.  Soni(>  of  the  lihres  are  apparently 
cniitinuuus  with  the  lihi-es  (if  the  t  hv  rua  ry  t  ein  lid. 

The  Lateral  Cricoarytenoid  is  somewhat  smaller  than  the  i>oste- 
rior.  It  s|irinL;s  hy  a  rather  lnnad  base  from  about  the  middle  third 
of  the  upper  herder  nf  the  lat<'ral  part  nf  the  ericnid  arch  and  also 
from  the  neiyhhcirinn'  part  uf  the  cricotliyroid  niemhrane.  Its  filires 
nmuin.y  backward  ami  upward  eiiu\-ei-i;c  to  i>e  inserted  into  tiie  fimit 
of  the  muscular  process  n\'  the  ai'ytenoid  cartiia.iAC 

The  Thyroarytenoid  Muscle  coiisist.s  of  two  jiarls.  an  external  and 
an  internal,  which,  however,  are  (dosely  blended.  .\  lar^ic  jiart  of  the 
lower  bordei'  of  this  muscle  is  clusely  associated  with  the  upjier  l>()rder 
of  tile  lateral  cricoarytemiid. 

The  External  Thyroarytenoid  Muscle  is  a  hinad  slu'et  just  within 
the  ala  of  the  thyroiil  cartiiaue  and  spreads  from  tiie  upper  snrfa<-e  of 
the  lateral  ci-icoaryteuoid  to  ahoxc  the  lexi'l  of  the  xncal  eoi-d.  It  arises 
in  front  from  the  lower  half  of  the  tliyioid  ala  (dose  to  the  auule  and 
also  from  a  ixntion  of  the  lateral  cricot  liNfoid  meiidu-aue.  Its  fibres 
rminin.u-  l)ackwai'd  parallel  with  the  \deal  cord  are  in>ei-ted  for  the 
fjreater  ])art  into  the  muscular  jn'ocess  of  the  arytenoid  cartilai-e.  A 
few  fibres  pass  around  this  caililau'e  and  are  continuous  with  the  trans- 
verse liiires  of  the  arytenoid. 

The  Thyroepiglottic  Muscle  is  reall>-  an  oil-shoot  from  the  np|>er 
border  of  the  exteinal  thyroarytenoid  which  turns  upward  to  lie  in- 
serteil  into  tlu'  upper  part  of  the  arylenoepiulottic  fold  and  the  free 
mar.iiin  of  the  epi.ulottis. 

1'he  Internal  Thyroarytenoid  Muscle  is  triamzniar  in  cross  sec 
tion  and  (dosely  associated  with  the  vocal  cord,  it  arises  from  the 
thyroid  anule  in  front  and  is  inserted  first  by  several  niiiscnlar  slips 
into  the  vocal  cord  itself  and  second  into  the  outer  side  of  the  vocal 
process  and  adj(iinin<;  outer  surface  of  the  arytenoid  cartila,i,'e. 


iH  OPERATIVE   ST'nOEKY   OF   THE   XOSE.   THIIOAT.   AXD   EAR. 

The  portion  dt'  tlic  inusi-lc  wlik-li  is  iuscrlcd  into  tlic  cord  is  some- 
times spoken  of  as  the  aryvocalis  iimsele. 

The  Action  of  the  Muscles  of  the  larynx  is  conct'rned  ))oth  with  the 
movement  of  the  \oeal  eords  and  the  eh)snre  of  the  upper  hiryn,n-eal 
aperture. 

The  cricothyroid  acts  as  a  tensor  of  the  vocal  curds  Ijy  tilting  the 
thyroid  cartilage  downward  and  forw^ard  (oblique  fibres)  and  by  pull- 
ing the  cartilage  as  a  Avhole  slightly  forward  (transverse  fi.bres).  As 
the  arytenoids  are  prevented  from  riding  forward  on  the  top  of  the 
cricoid  lamina,  this  forward  tilting  of  the  thyroid  cartilage  must  put 
tension  on  the  vocal  cords.  In  opposition  to  this  action  of  the  crico- 
thyroid, the  thyroarytenoid  relaxes  the  vocal  cords  by  approximating 
the  angle  of  the  thyroid  cartilage  with  the  arytenoid  cartilage.    While 


Fig.  66. 
Diagrams  illustrating  closed  iuid  open  glottis. 
1,  Thyroid  cartilage;  '2,  Thyroarrtenoideus  internus;  .'3,  Cricoar^-tenoi- 
deus  lateralis;  4,  Ai-ytenoid  cartilage;  5,  Crieoaiytenoideus  posticus;  6, 
Arytenoideus  transversus;  7,  Cricoid  cartilage;  8,  Thyroid  cartilage; 
9,  Th_yroaiyt.pnoideus  internus;  10,  Cricoarrtenoideus  lateralis;  11,  Aryte- 
noid caitilage;  12,  Cricoarytcnoidous  posticus;  13,  Arytenoideus  trans- 
versus;  14;   ('ricoid  cartilage. 


the  thyroarytenoid,  as  a  whole,  relaxes  the  whole  vocal  cord,  it  is  prob- 
able that  the  falsetto  voice  results  from  a  partial  contraction  of  the  in- 
ternal thyroarytenoid  by  relaxing  only  a  ])ortion  of  the  cord  while  the 
cricothyroid  makes  the  remaining  part  of  the  cord  tense,  the  tense 
])ortion  only  being  capable  of  vibration.  The  posterior  cricoarytenoid 
muscle  by  rotating  the  arytenoid  cartilage  so  that  the  vocal  process 
turns  outward,  is  the  abductor  of  the  cords  while  the  lateral  cricoaryte- 
noid niuscle  by  rotating  it  in  the  oi)posite  direction  liecomes  the  ad- 
ductor of  the  cords. 

The  transverse  arytennid  muscles  bi'ing  the  central  sides  of  the 
arytenoid   cartilages  together  and   thus   complete  the   closure   of  the 


sruciCAr,  axatomv  or  tiik  piiai:vn-x.  i.ai;vnx.  ani>  nkck.  ?!• 

lilottic   rlliiil<    ;irti'i-    tllc    \nr;il    ccililv    |il-ii|ic|-    llllVc    Iiith    ;i  )  i|  H'i  i\  i  lli;it  cd    liV 

till'  iiiwnrd   i-ol,-ili(>ii  iif  ihr  ;ii-\  li'iiiiiil  rnrlilimi'. 

'I'lu'  <-l(iMiii'  (if  tllc  su|HTiur  lar\  iiiii'iil  ;i|ici'tiUT  diiriiii;'  swallow 
inu:  is  nceoiniilislicil  cliitllv  liy  tlic  ol)li(|iU'  itortioii  of  tlio  arytenoid  net- 
inn-  in  oonccii  witli  tlir  arytcnociii^lollic  iinisrlc-.  Tlic  transverse 
arytenoid  with  the  tliyroarx  Iciidicl  miisidis  pnihaldx  aiil  in  the  closure 
by  appi'oxiniatiii.u'  the  ai\tciu)id  cartihiiics  and  c(iniiiics>inL;'  the  sides 
of  tlie  larynx  at  almut  the  position  of  the  false  \ncal  cords.  The  sn- 
l>erior  aperture  when  c|(i>ci|  |.ri'<cii1s  a  "'r"  -liaped  fissure  ■with  the 
top  of  the  "T""  apprdximately  parallel  with  the  transverse  axis  of  the 
epiii'hittis  and  the  >teni  runniui;'  helween  the  two  arytenoid  bodies. 
The  nius(des  therelnre  which  affeet  this  closure  nuist  be  looked  upon 
in  elTeet  as  true  s])hincters. 

The  Nerve   Supply   of  the   Larynx. 

The  nerves  siippl\  in:.;  the  lar\nx  are  two  in  nnniher,  and  bnth  are 
branches  of  the  ))ncnni<iL;astric  or  xaun-. 

The  Superior  Laryngeal  Nerve  lea\e>  thi'  \a.nus  hii:h  nji  in  the 
neck,  and  jiasses  obli(pudy  downwar<l  and  forward  on  the  inner  side  of 
the  intenuil  and  external  earoti<l  arteries.  On  approachiui"-  the  larynx, 
it  divides  into  two  nneipial  parts,  a  lai'i;'ei-  internal,  and  a  smaller  ex- 
te?-nal  lu'anch. 

The  Internal  Laryngeal  Nerve  passes  hctwi'en  the  middle  and  in- 
ferior pharyn.neal  constrictors  and  reaches  the  interior  of  the  larynx 
by  penetrating-  the  thyrolixoid  memhrane.  Sensation  is  supjilied  by 
this  nerve  to  the  mucous  memln-ani'  of  the  larynx  from  the  e]iiii:lottis 
down  to  the  njiper  part  of  the  tra<-liea.  This  nerve  probably  also  con- 
tains \'asoniotor  and  >ecretory  lilires,  which  it  supplies  to  the  whole  of 
the  laryu.neal  mucous  nieud)rane. 

The  External  Larjmgeal  Nerve  runs  downward  on  the  external 
surface  of  the  inferior  constrictor,  endiui;-  at  the  ei-icolhyroid  muscle 
which  it  sniiplies.  liranches  aie  sent  to  the  iid'erior  constrictoi-  nmscle 
and  probably,  a  I'ew  motor  twius  iia>>  to  the  ar\t<-uoid. 

The  Recurrent  or  Inferior  Laryngeal  Nerve  leaves  the  jiueuuio- 
i;'astric  in  the  lower  part  of  the  ue<ds,  and  turns  upward  to  supply  idl 
of  the  intrinsic  muM-les  of  the  larynx  except  the  cricothyroid,  and 
part  of  the  arytenoid. 

THE  LYMPHATIC  SYSTEM  OF  THE  NECK. 

The  cervical  Ixiupiiatic  nodes  are  dixidcvl  into  two  main  n^roups, 
the  superlicial  or  collecting-  nodes  and  the  deep  or  terminal  no(les.    The 


80  oi'KitA'i'ivK  sri;i;Ki;v  ni-  thio  nosk,  thiwiat.  ami  kai:. 

su])crru-i;il  L;rim|i  is  ai'i'jiiiiiX'd  as  a  sort  nl'  a  collai'  around  the  ii|i)i('i- 
jiart  of  tlic  iH'ck  Avilli  a  Few  irro.milai-  oxti'iisions.  This  ]KTic('r\ical 
rii'clc  is  coinposed  of  the  I'ollowing- siil)groii|is: 

1.  Subocf'ipital  gi'oiip  and  aberrant  glands  of  tlu'  nape  of  the  neck. 

'2.  Mastoid  grou|i. 

.">.  Parotid  and  snhparotid  gron]). 

4.  Submaxillary  grou])  witli  llic  I'acial  glands  as  an  off-shoot. 

5.  Submental  group. 

().  Retropharyngeal  gron]). 

The  Suboccipital  Group  of  glands  aic  rather  inconstant  struc- 
tures var\  ing  fVom  one  to  three  in  nnmher  an<l  nsindly  are  placed  on 
the  occipital  insertion  of  the  complexns  muscle  just  external  to  the  ex- 
ternal border  of  the  trapezius.  They  receive  the  lymph  vessels  from  the 
back  of  the  head  and  their  efferent  vessels  terminate  in  the  highest 
nodes  of  the  substernomastoid  gron]i. 

The  Mastoid  Group  or  retroaui-icnhu-  glands,  generally  two  in  num- 
ber, lie  on  the  mastoid  insertion  of  the  sternomastoid.  These  glands 
recei\e  their  afferent  vessels  from  the  temporal  portion  of  the  hairy 
scalp,  from  the  internal  surface  of  the  auricle  except  the  lobule  and 
from  the  posterior  surface  of  the  external  auditory  meatus.  They 
emi»ty  into  the  highest  glands  of  the  deep  lateral  chain. 

The  Parotid  Group  consists  of  glands  in  the  iiarotid  space  either 
external  to  the  glands,  the  superficial  nodes,  or  in  the  actual  substance 
of  the  parotid,  the  deep  nodes.  The  deeper  i)arotid  nodes  are  scat- 
tered throughout  the  substance  of  the  parotid  but  for  the  most  part 
are  grouped  around  the  external  carotid  artery.  They  are  (piite  nu- 
merous though  some  are  very  small  and  can  be  seen  only  by  the  micro- 
scope. These  glands  receive  afferent  vessels  from  the  external  surface 
of  the  a^iricle,  from  the  external  anditoi/y  meatus,  from  the  tympanum, 
from  the  skin  of  the  tenipoi'al  and  frontal  regions  and  jxisslbly  also 
from  the  eyelids  and  base  of  the  nose.  It  is  possible  that  at  times 
they  drain  the  nasal  fossfe  also  and  the  posterior  part  of  the  alveolar 
border  of  the  superior  maxilla.  The  atferents  run  into  the  upper  sub- 
sternomastoid glands  near  the  exit  of  the  external  jugular  vein  from 
the  parotid. 

The  Subparotid  Glands  belong  in  reality  to  the  parotid  group  but 
are  placed  beneath  the  ]iarotid,  between  it  and  the  phai'yngeal  wall  in 
the  lateropharyngeal  space.  Suppurative  inflammation  of  these  glands 
gives  rise  to  lateral  pharyngeal  abscesses.  Their  aft'erents  come  from 
the  nasal  fossae,  from  the  nasophai'vnx  and  from  the  Eustachian,  while 
their  efferents  pass  to  the  upper  glands  of  the  deep  cervical  chain. 


srr,(;icAi.  axawmv  ov  tiik  piiauynx,  r.AnYXX,  and  xkck.  81 

'I'lic  Submaxillary  Group  ciiiisists  df  rrnin  three  tc  >i\  immIcs  situ- 
ated nlon--  the  leiiulli  i<\'.  aii.l  imiiiediately  lieneatli.  tlie  luwei-  Imr.ler 
of  the  iiuuulil)le.  The  iai'nest  of  the  urniip  is  generally  fouml  near  tiic 
facial  artery.  These  glands  ai'e  Just  lieiiealli  tlie  fascia  ami  are  inure 
or  less  intinn»tely  associated  with  the  n]i|H'r  Imrder  nf  the  snlnnaxil 
hiry  salivary  inland.  Theii-  afreieiit  \  i'>^e|-  cduic  frcini  the  external 
uose,  the  cheek.  iVoni  the  npiier  and  liie  external  part  <<['  the  Iciwer  lip, 
front  practically  the  whtih'  nf  the  i;nnis  and  fruiii  the  anterior  third  of 
the  sides  of  the  Inni^ne.  The  efferent  \essfls  ruuuinii'  o\er  the  surfaci' 
of  the  snhniaxillar_\  sali\ai-y  izlands  empty  o-cuerally  into  tin  i;-lands 
of  the  deep  eei\ieal  chain  near  the  hifnrcatidii  uf  the  cdnnnon  cai'otid. 
.They  nniy  at  tinu'>  pass  [n  ^lamls  farther  dnwu  the  chain. 

The  Facial  Glands  are  small  inconstant  structures  found  in  the 
course  of  the  afferent  \-essels  leading-  to  the  snlimaxillary  nodes.  They 
gXMicrally  form  thrive  i^ronps.  The  inferior  or  supramaxillai'v  rest  on 
the  jaw  just  in  front  of  the  massetei-  mnsde.  (  )ccasioinUly  there  is  a 
gland  immediately  on  the  edi;.'  of  the  jaw  at  this  ])osition  called  the 
iuframaxillary  gland.  .\  less  ficipn'nt  uroup  of  glands  is  the  middle 
or  l)ucoinator  group  on  the  external  snrface  of  the  Iniccinator  mus- 
cle. All  of  these  hnccinator  glands  lie  ijutside  of  the  buccal  fascia. 
There  may,  however,  he  a  snM'as  ial  inland  or  a  snlnnncous  s>iaud.  The 
third  gronj)  is  >till  less  constant  and  is  situated  jnsf  to  one  side  of  the 
uose. 

The  Submental  Group  consisting  of  fi-om  one  to  fonr  glands  are 
found  in  the  triam^le  hounded  hy  the  anterior  heilies  of  the  two  <li- 
gastric  mus(des  and  the  liquid  hone.  The  alTi'rent  vessels  of  this  group 
are  from  the  skin  of  the  cinn  from  the  centre  |)ortiou  of  the  lower  lip 
ami  from  the  mncoirs  memhrane  coxcring  the  (>xterual  ))ortion  of  the 
alveola-.  iVom  the  lloor  of  the  month  and  from  the  li])  ol'  tlie  longne. 
The  efferent  \-essels  iMin  either  t<i  the  snlimaxillary  gland  oi'  directl\' 
downwai'il  to  a  imde  of  the  deep  cerxical  chain  situated  on  the  internal 
jngnlar  \-ein  just  ahoxe  where  it    is  cros-ed  hy  the  omohyoid. 

The  Retropharjmgeal  Group  consisting  generalh  of  two  glands  is 
l)laeed  hack  of  the  posttM'ior  jiharyugeal  wall  ueiir  its  outei-  vdiiv  being 
almost  1^  cm.  fi-om  the  median  line.  These  glands  are  separated  from  the 
atlas  hy  the  rectus  ca|iilis  anticns  niajoi-  mnside  and  are  in  rather  close 
relation  exlernall>  with  the  >heath  of  the  givat  \e»el.-  ol'  the  neck. 
Snppurati\e  intlanmial  ion  of  the  mides  leads  to  ret  I'ophai'yngeal  ab- 
scess. In  this  case  the  ai)scess  starts  laterally  but  bt'ing  limited  ex- 
teniall)  h\  the  fascia  covering  the  vessels  enlai'ges  medianward.  <  tc- 
casionally  theie  aic  small  inconstant  nodes  l)aek  of  the  pharyngeal 
wall  ahnost    in   the  median   line.     The  I'etropharyimc  al  glands  receive 


812  0PEI;ATIVE    SnUiEItY    of   the    XOSE,    TirROAT.    AND    EAR. 

tliciv  ;ilTci-ci)ts  ri-diu  the  luucous  iH('iii1)i';nic  of  the  nasal  tossiP  and  i\c-- 
<-('ss(ii-y  sinuses,  JVoin  tin.'  iiasdjiliarynx  iiicliHlin^i'  tlic  |ilLaryii,'4cal  ton- 
sil, rniiu  tile  region  of  tile  Kustaeliian  tube  and  possibly  from  a  part 
of  tile  tyiiipanic  cavity.  It  must  be  said,  however,  that  the  retrophar- 
yngeal h'mi)]iati(!  glauds  are  only  interrupting-  nodes  plaeed  on  the  col- 
lecting lymphatics  as  they  pass  from  the  ui)per  ^jart  of  the  back  of  the 
tliTdat  to  the  posterior  group  of  the  deep  cervical  chain.  The  att'erent 
lymph  vessels  of  the  retropiharyngeal  lymph  glands  follow  the  same 
general  course  as  those  efferents  which  come  directly  from  the  i)oste- 
ricn-  ])hai'yngeal  wall  and  ]iass  behind  the  great  vessels  of  the  neck  to 
reach  tJie  ]iosterioi-  vdtxi'  of  the  stei'nomastoid  muscle,  and  em]>ty  into 
the  ujipcr  nodes  of  the  ])osterior  grouj)  of  the  doe]i  cervical  chain. 


Fig.  G7. 
Dissection  sliowiug  the  upper  deep  cervical  lympli  nodes. 
1,  Masseter  muscle;  2,  Facial  artery;  3,  Submaxillary  gland;  4,  H-ypo- 
glossal  nerve;  5,  Digastric  (posterior  belly)  and  stylohyoid  muscles;  6, 
Anterior  group  of  the  deep  cervical  lymph  nodes;  7,  Facial  nerve;  S, 
Kxternal  jugiilar  lymph  node ;  9,  Sternomastoid  muscle ;  10,  Posterior  group 
of  the  deep  cervical  l^inph  nodes;  11,  tSpiual  accessory  nerve;  12,  Sterno- 
iiKistoid  artery;   1?.,  Iiitcinal  jugular  vein. 


The  Descending-  Cervical  chain  of  lymph  nodes  consists  of  two  sets 
of  glands,  the  deei>  cervical  chain  and  several  more  or  less  important 
secondary  and  more  superficial  chains.  The  deep  glands  situated  on 
each  side  of  the  neck  comprise  from  fifteen  to  thirty  nodes  on  an  aver- 
age, although  these  figures  do  not  represent  tlie  extremes  of  variation. 
This  group  of  glands  is  variously  termed  the  <'ai'otid  chain,  the  sub- 


SlT.dHAr.    AXATiiMV    dl'     I'llK    I'llAKVNX.    I.AIIVNX,    ANH    NKCK.  8ii 

stcnicHiiasldiil  -nmji,  (H-  llic  ilcc)!  hiliTjil  ul;iii<ls  df  tlir  iifck,  iiuA  iii;iy 
tliciu-ctir;ill\  aihl  fli  nir;i  1 1  \  !„■  .Ii\i.|r,|  iiiiii  two  -rdUii-.  n  1 1  lioii,<;-li  aiia- 
t(iiiiit-;ill\  lln'>  ;ii-f  rliisrlx  asMK-iatcd.  Tlicv  cxtcrul  rnnii  jusl  liciiratli 
llic  car  ildwiiw  aid  iiiidcr  tlic  stoiidclciddiiiastdid  iiuiscK'.  i;('iifrall\' 
only  as  far  as  llic  pdint  wlicrc  the  diiidlivdid  crus-cs  llic  vessels  and 
nci'\-c<,  lull  dccasidiially  icachin^'  as  i'ar  as  llic  jiiih-lidii  i>\'  the  internal 
jniiiilar  and  >iiiHda\iaii  \ciii.  The  nidre  siiiici-lieial  di\i-idn  nf  the  deeii 
lateral  chain  lies  |idstci-idrly  and  is  called  tlie  cxtenial  m-diip.  'I'he 
external  lilands  arc  generally  small,  and  |ilaced  in  part  ln'iieath  the 
I'dsteridi-  hdrder  df  the  sli'rndclciddinastdid.  and  dcca>idnall\  extend  so 
far  ddwn  the  anterior  hdrder  of  the  trapezius  niiisi-le  as  td  cdinc  into 
rather  eldse  relatidii  with  the  siipraela\"icnlar  glands.  They  rest  rather 
'irroii'niarly  disli  ilniied,  dii  the  external  -nrface  of  the  -pleiiiii^.  levator 
aiiii'nli  scapnki'.  ecrxieal  plexus  ami  the  spinal  accessdi\   nerve 

The  anterior  dr  deep  dixisidii  iA'  the  main  L;rdiip  is  jilaccd  directly 
over  tlie  groat  vessels  of  tin-  neck,  and  is  termed  tiie  internal  jugular 
group.  These  nodes  are  situated  beneath  the  anterior  border  of  the 
stenidcleiddinastdid  mn<elc.  and  wlii'U  enlarged  may  he  I'drced  anteri- 
oi'ly  until  Mime  of  iIkmii  appenr  immediately  hehiw  the  angle  dl'  the  jaw. 
( )ne  or  two  large  glands  arc  cunslantly  I'dinid  hcldw  the  postericu'  helly 
of  the  digastric,  jusl  ahdvc  the  spot  where  the  tliyrdlingiuil-facial  vein 
opens  into  the  internal  jnunlar.  These;  nodes  receive  lyinj^ilmtics  from 
the  tongue  ■while  ininic(|iately  ahd\-c  the  digastric  is  a  large  node  which 
drains  the  tonsil  and  snrrdiinding  leiiidii.  A  few  glands  are  sometimes 
found  between  the  inti'rnal  Jiii^nlar  and  the  prevertebral  muscles. 

The  Accessory  or  Superficial  Descending-  Cervical  chain  consists 
of  four  groups,  the  extei'ual  jugular  chain,  the  suijerficial  anterior  cer- 
vical chain,  the  deep  anterior  cervical  chain,  and  the  recurrent  chain. 

The  ExTERX.AL  JuGi'LAK  Chaix  consists  usually  of  two  or  three 
nodes  resting  on  the  extei-nal  snrrac(>  df  the  >tenidmastdiil  just  below 
the  pai'dtiil  -land.  (  )ccasidiially  diie  nr  1wd  iidde>  are  fdiind  rnrlher 
down  along  the  course  of  the  xcins.  Their  alTerent  vessels  come  from 
the  auricle  and  parotid  i-egioii  and  their  clTerent  vessels  terminate  in 
the  u|i]icr  nodes  of  the  deej)  cervical  chain.  It  is  claimed  that  some- 
linics  an  efferent  vessel  from  these  glands  may  follow  along  the  course 
of  the  exteiMial  jugular  M'iii  and  i-nipty  into  the  Mipraclavicular  glands. 

The  Si'i'KKnciAi.  Axtkukik  ('kuvuai.  Chain  eonsi^ts  of  two  or  three 
inconstant  nodes  on  the  anterior  jugular  vein. 

The  Deep  AxTEiuoR  Cekvic.\l  Ciiaix  may  be  .lixideil  inld  ihrce  dis- 
tinct groups:  the  ])relaryngeal,  the  prethyroid  and  pretracheal. 

The  prelaryngeal  grou])  consists  of  one,  two  or  three  inconstant 
glands  most  frequently  found  in  the  triangular  space  bounded  by  tlio 


84  (U'i:i;.\TivK  snjdKKv  of  the  xose,  tiihoat.  axd  ear. 

two  cricotliN mill   imiscles.     A\'liou  ]irost'nt  tlicir  al'IVreiils  coino  from 
the  iiiiililli'  l\  iiijiliatic  pedicle  of  the  larynx.     Tlioir  elTereiits  may  run 
I'illicr  to  tlic  pri't  laclical  nodes  or  to  the  lower  nodes  of  the  deep  lateral- 
(;haiii. 

'l\\r  prctliyroid  .<;laiids  are  usually  absent. 

The  pret laclieal  urou])  is  usually  present  and  consists  of  one  or 
more  \('i-\-  small  nodes.  Their  afferents  come  from  the  thyroicl  body 
and  the  i)relaryngeal  nodes  and  their  eiTerents  terminate  in  the  lower 
nodes  of  the  deep  lateral  chain. 

Tiie  Recurrent  Chain  consists  of  from  three  to  six  minute  nodes 
along-  the  course  of  the  recurrent  laryngeal  nerves.  Their  atlerent  ves- 
sels come  from  the  inferior  pedicle  of  the  larynx,  from  the  neighbor- 
ing- region  of  the  trachea  and  esophagus  and  a  part  of  the  thyroid  body. 
It  is  im])oi'tant  to  remember  that  the  efferent  vessels  of  this  cliain 
terminate  in  tlie  inferior  nodes  of  the  deep  lateral  chain  instead  of  pro- 
ceeding dowiiwai'd  to  the  mediastinal  glands.  It  is,  however,  possible 
that  occasionally  an  efferent  Fi'din  these  nodes  passes  directly  to  the 
superclavicular  glands. 

The  Supraclavicular  Group  of  lymph  glands  occupies  the  supra- 
clavicular or  sTdiclavian  triangle.  These  glands  are  generally  very 
numerous  and  are  imbedded  in  the  adipose  tissue  found  in  this  triangle 
the  so-called  "fettpolster"  of  Merkle.  In  the  upper  part  of  the  triangle 
they  are  just  beneath  the  superficial  cervical  fascia  and  rest  on  the 
splenius,  levator  anguli  scapulae  and  scalenus  muscles.  Also  they 
hold  important  surgical  relations  with  some  of  the  lower  branches  of 
the  cen'ical  plexus  which  supply  the  trapezius  and  with  the  ascending 
cer^■ical  arteiy.  The  more  inferior  glands  of  this  group  are  in  greater 
part  placed  in  front  of  the  middle  layer  of  cervical  fascia  lying  very 
close  to  the  tenninal  subfascial  portion  of  the  external  jugular  and 
descending  branches  of  the  ceivical  plexus.  Some  nodes  more  deeply 
placed  are  found  behind  the  omohyoid  and  the  middle  layer  of  cervical 
of  the  subclavian. 

The  majority  of  authors  place  this  chain  of  glands  as  an  auxiliary 
fascia  being  just  in  front  of  the  brachial  plexus  and  the  third  portion 
group  of  the  deep  cervical  chain,  but  my  own  researches  have  led  me 
to  believe  that  the  supraclavicular  nodes  rarely  show  any  anastomosis 
with  any  of  the  cervical  lymph  nodes.  This  is  a  most  important  ana- 
tomic feature  because  a  direct  coimection  between  these  nodes  and  the 
cervical  lymph  glands  would  establish  the  necessary  link  in  the  hon- 
phatic  chain  fi'om  the  tonsils  to  the  apex  of  the  lung. 

The  afferents  of  the  supraclavicular  glands  come,  first  from  the 
posterior  part  of  the  scalp  and  fi'om  the  muscles  of  tlie  neck,  second 


srr.cu'Ai.  ANAiiiNn   oi'   iiii'.  l•ll.\K^^■\,  i.akvnx.  anh   nikk.  ^^ 

from  tlic  sUiii  of  llic  iicclm-.-il  ii'L;inii.  iliiid  riniii  tln'  skin  of  the  ;ii-iii 
owv  till'  (■(■|il:;ilic  M-iii.  rouilli  rinin  tlic  liiiiiicfjil  cli.-iiii  n\'  ilic  .-ixillMry 
group  of  lA'lands,  and  lil'll:  idouliti'd  li\  sonic  aiillior>  i  iVnin  tlic  pai'lctal 
pleura  covoriiii;-  llic  apex  of  (•;icli  Iuml;.  The  I'lTniMit  \rssi'l  of  llie 
supraclavicular  yiands  generally  empties  inlo  llic  jni^ular  Iruuk. 

The  ju?;ular  lymphatic  trunk,  tiic  terminal  vessel  of  the  deep  lateral 
chain,  usually  tcnuiuatcs  on  the  rij>ht  side  in  the  anj-le  of  junction  of 
the  internal  jugular  and  suliclavian  veins.  On  the  left  side  it  nH)st 
tVeipientl>"  tei-iniuates  in  the  thoracic  duct. 

TOPOGRAPHIC    ANATOMY    OF    THE    ANTERIOR    CERVICAL 

TRIANGLE. 

Viewed  fi'om  the  side,  ilie  m^ek  is  divlilecl  hy  tln'  >ici  imcdeido- 
mastoid  muscle  into  two  triangles,  an  anterior,  and  a  posterior  triani,de. 
The  antiM-ior  cei-vical  triaui^-le  is  sididi\ideil  into  a  diiiastric  (suhuuixil- 
lary),  a  carotid  (suiterior  carotid)  and  a  muscular  (inferior  carotid) 
triauule  iiy  the  disi'astric  and  onu)hyiiid  mn-ch'^.  while  the  ])Osterior 
triauiide  is  divided  by  the  jjosterior  ludly  nf  the  (iniohyoid  Into  *he 
occipital  and  supraclavicular  triauiiles. 

The  skin  of  the  neck  is  loosely  attached  and  tlic  cicases  and  folds 
formed  by  the  flexion  of  the  head  as  a  nde  run  from  above  and  behind 
obliquely  forward  and  downward.  It  is  important  to  remember  the 
direction  of  these  foLls  as  incisions  hi-al  with  less  deformity  when 
made  either  in  the  fold  it-elf  oi-  iiarallel  with  its  course.  In  the  lower 
part  of  the  neck  the  folds  run  moic  trausx'erse,  and  the  incision  should 
then  be  less  oblique  followiui;-  the  dii'ection  of  the  skin  fissures. 

Beneath  the  skin  is  the  superficial  fascia.  Tiiis  fa.scia  is  continu- 
ous with  that  of  the  head  and  chest,  and  contains  the  superlicial  nerves 
and  blood  vessels,  none  of  which,  however,  have  any  .ureat  surgical 
importance. 

Between  the  sujterficial  fascia  and  the  deep  fascia  is  jdaced  the 
phitysma  myoides  muscle.  ^'Iiis  muscle  is  a  thin  sheet  covei-inij  the 
antei'ioi-  part  of  the  siile  of  tin'  iii'ck,  arisini;'  from  the  deeji  fascia  of 
the  i)ectoral  region  and  from  the  clavicle.  Its  fibres  extend  upward  and 
slightly  forward.  The  greater  part  of  the  muscle  is  inserted  into  the 
lower  border  of  the  jaw  but  some  of  the  libres  are  cuntinudus  with 
the  depressor  labii  inferioris,  the  depressor  auguli  oris,  and  the  risorius. 
The  anterior  fibres  meet  across  the  middle  line  just  below  the  chin. 

Just  beneath  the  posterior  part  of  the  platysma  is  the  external 
jugular  vein.    The  line  of  this  vein  is  from  the  angle  of  the  jaw  to  the 


86 


ll'KI'.A  TIVK    .SLT,(;K1;Y    of    the    nose,    TIHIOAT,    AXn    EAR. 


iiiiildlc  111'  the  i-];i\irlc.  It  is  t'oi-incd  liy  the  .jiiiiclinii  oT  Iho  jiostorior 
;niri('ul;ir  \-ciii  with  tlic  iHislci-iov  l)r;iiic]i  of  tlic  tcin|i(ir(iin;i\ill;ii-y  vein. 
It  pHHSi's  (low  iiwaitl  external  to  tlie  deep  fascia,  crossing  obliquely  over 
the  sternoniastoid  muscle,  and  pierces  the  deep  fascia  in  the  anterior 
part  of  the  subclavian  triangle.  It  crosses  in  front  of  the  third  part 
of  the  subclavian  artery  and  empties  into  the  subclavian  vein. 

Ahnost  immediately  posterior  to  the  vein  running  parallel  with  its 
upper  part  will  be  found  the  great  auricular  nerve.    This  nerve  is  the 


Fig.  fiS. 
Superficial  dissection  of  tlie  carotid  triangle. 
1,  Masseter  muscle ;  2,  Facial  artery ;  3,  Su1)maxillarv  gland  ;  4,  Hypoglos- 
sal nerve;  .'5,  Anterior  group  of  the  deep  cervical  lymph  nodes;  6,  Sujjerior 
t.h^Toid  arteiy;  7,  Facial  nerve;  8,  Posterior  aui-ieular  arterj';  9,  External 
jugular  lym])h  node;  10,  Posterior  belly  of  the  digastric  muscle;  11, 
Sternomastoid  muscle;  12,  Posterior  group  of  the  deep  cervical  l\^u|lh  nodes; 
13,  Spinal  acccssoiy  nerve. 


largest  of  the  superficial,  or  cutaneous  branches  of  the  cervical  plexus. 
It  pierces  the  deep  cei'A'ical  fascia  just  above  the  middle  of  the  posterior 
border  of  the  sternomastoid  muscle  and  ascends  in  close  relation  wnth 
the  external  jugular  vein.  Immediately  beneath  the  ear  it  divides 
into  three  branches;  the  anterior  or  facial  branch  which  supplies  the 
skin  over  the  parotid  gland  and  anastomoses  in  the  substance  of  this 
gland  with  the  facial  nerve ;  the  auricular  branch,  which  supplies  both 


SURGICAL   AXAIdM  V    HV    TIIK    rilAUVNX.    I.Ar.VNX.    ANH    M".('K.  S( 

sidos  of  the  lower  part  nf  tlic  |iiiiiia:  ami  the  iiiaslniil  liraiirh.  wliicii 
siii)p]ios  tlio  ^kill  .if  \\\r  >calii  lioliiinl  ihc  cai-.  A1h,\c  tlir  aiii-icularis 
inau-inis.  tltf  small  .K'ci|iilal  iicrxc,  a  ln'aiicli  d'  iIk-  rrr\  ical  |ilc\ns  |i;issos 
upward  aloiiu-  the  pnsti'rini-  luirdcr  n\'  tlir  stci-|iniiia>luid.  .Inst  lu'lnw 
tile  ui-cat  auricular  nfi-\i'  tlir  supci-lii'ial  i-,.i-\ical  \uT\r  picrct'S  tlii' 
diM'p  fascia  and  passes  fnrwai'd  and  I  i-aii-\  cr-cl\  n\cr  the  stcnioiiins- 
tiiid  aud  liciicatii  the  external  Jni^'ular  vein. 

The  deep  t'ascia  i<\'  the  neck  invests  all  the  muscles  and  fornis 
apoiu'iirotic  covorings  fur  llu'  t'sopluigns,  piiarynx  and  tracliea,  cap- 
snlos  for  the  salivary  iilamls.  and  sheaths  for  the  larger  hlood  vessels. 
This  fascia  is  attached  hehiml  to  the  liganh'Utnm  nucha'  aud  the  spinal 
])rocoss  of  the  seventh  cervical  vertidna.  A  supcrlicial  layer  passes 
forward,  enveloping  the  trapezins  ninscle  and  uniting  in  front  of  the 
nmscle,  it  crosses  over  the  ])os1eri(n-  trianiile  of  the  neck  to  envelop 
the  stenioniastoid  muscle,  .\lio\i'  it  is  attached  to  the  mastoid  jirocess 
and  the  superior  cni-x-eil  lii I'  tl cci|iital  hone  aud  helow  to  the  clav- 
icle.    From  the  antm-ior  edLiv  of  the  sternnma^toid  muscle  it  continues 

forward  to  the  median  lit I'  the  neck  in  a  single  layer.     In  the  front 

]iart  of  the  neck  the  upper  attachment  is  to  the  lower  border  of  the 
jaw.  the  styloid  process,  and  the  hyoid  hoiu'. 

Below,  near  the  steninm.  it  dixides  into  two  layer.s,  an  anterior  and 
a  ])osterior  which  aic  attached  i-espectively  to  the  anterior  and  pos- 
terior edges  of  the  upjx'r  ])ortion  of  the  sternum.  The  interval  thus 
fonued  (the  space  of  Gruher)  contains  fat,  the  sternal  head  of  the 
stenioniastoid  and  the  anterior  jugidar  veins. 

Just  below  the  mastoid  process  a  su])erHcial  layer  of  the  deep 
fascia  is  continued  over  the  parotid  gland  and  the  masseter  muscle  as 
the  i^arotid  and  masseteric  fascia,  anil  is  attached  to  the  lower  border 
of  the  zygoma. 

From  the  deep  fascia  processes  extend  between  the  various  struc- 
tures of  the  neck.  At  the  angle  of  the  jaw  it  becomes  thickened  and 
fomis  the  stylomandibulai'  ligamiiit,  which  extends  from  the  tip  of  the 
styloid  process  to  the  posterior  hoidei-  of  the  angle  of  the  mandible. 
Other  thickenings  of  this  fascia  form  the  i)teiygospinous  ligament 
and  the  stylohyoid  ligament.  This  latter  ligament  runs  from  the  tip 
of  the  styloid  process  to  the  lesser  coniu  of  the  hyoid  bone. 

Two  main  processes  are  given  off  from  tiie  deep  fascia,  a  posterior 
and  an  anterior.  The  posterior  jjrocess,  or  prevertebral  fascia,  arises 
at  the  anterior  border  of  the  trapezius  mustde,  and  covers  the  numer- 
ous muscles  of  the  back  of  the  neck,  the  brachial  plexus,  the  phrenic 
and  cervical  sjnnpathetic  ner\'es  and  passes  inward  behind  the  large 
vessels,  the  phaiynx  and  the  esophagus  to  meet  its  fellow  of  the  other 


88  <iim-;i;ativk  sriicKKV  of  the  xose,  thiioat,  axu  kak. 

si.k'.  It  is  attai'lii'il  alnix-c  [n  the  l)ase'  of  tlu'  skull  ami  lidow  to  the  first 
rib  as  far  forward  as  the  anti'iior  iiordcr  of  the  aiilcrioi-  scalenus  iiiusclc. 
It  also  passes  down  into  the  chest  o\-er  the  1ou,l;iis  colli  muscle  and  the 
bodies  of  the  vei-telira'.  It  forms  the  sheath  of  the  sulxdavian  and  axil- 
lary vessels  by  a  process  beginning  jnst  ontside  of  the  anterior  scalenus 
muscle.  In  conjunction  with  the  anterior  process  it  forms  the  sheath 
of  the  carotid  artery  and  internal  jugular  vein. 

The  anterior  process,  or  ])retracheal  fascia,  passes  inward  and  for- 
wai-d  from  the  auteiior  bolder  of  the  sternomastoid  just  in  front  of 
the  trachea,  and  envelops  the  thyroid  gland.  It  is  attached  below  to 
the  first  rib. 

The  deep  cervical  fascia  surrounding  the  trachea  and  the  great 
vessels  follows  these  structures  down  into  the  chest  where  it  is  con- 
tinuous with  the  fibrous  layer  of  the  pericardium.  The  prevei'tebral 
and  the  pretracheal  fascife  divide  the  neck  into  three  compartments. 
The  anterior  compartment  contains  the  anterior  belly  of  the  omohyoid, 
the  sternothyroid  and  the  sternohyoid  muscles.  The  middle  contains 
the  pharynx,  esophagus,  trachea  and  the  thyroid  gland;  while  the  pos- 
terior contains  the  vertebral  column,  the  upper  vertebral  muscles,  the 
scalene  muscles,  the  levator  anguli  scapulae,  and  the  whole  musculature 
of  the  back  of  the  neck  with  the  exception  of  the  trapezius. 

The  most  important  compartment  formed  by  the  deep  cervical 
fascia  is  the  visceral  compartment.  This  compartment  is  bounded  an- 
teriorly by  the  pretracheal  fascia,  postei-iorly  by  the  preverteliral  fascia 
and  laterally  by  the  fascia  forming  the  sheath  of  the  deep  blood  vessels. 
It  extends  from  the  base  of  the  skull  downward  into  the  posterior 
mediastinum.  In  front  it  runs  from  the  hyoid  bone  into  the  anterior 
part  of  the  superior  mediastinum. 

The  Sternocleidomastoid  Muscle  is  the  most  prominent  muscular 
landmark  of  the  neck.  It  forms  a  distinct  ridge  of  swelling,  running 
from  the  mastoid  process  downwai'd  and  forward  across  the  side  of 
the  neck  to  the  region  of  the  sternoclavicular  articulation.  It  has  two 
heads,  one,  the  sternal  head,  a  narroAV  tendinous  structure  which  arises 
from  the  anterior  surface  of  the  manubrium  of  the  sternum,  and  a  cla- 
vicular head,  broader  and  only  partly  tendinous,  Avhich  arises  from  the 
upper  surface  of  the  inner  third  of  the  clavicle.  It  is  inserted  by  a 
rather  broad  attachment  into  the  outer  surface  of  the  mastoid  process, 
and  into  the  adjoining  portion  of  the  superior  curved  line  of  the  occip- 
ital bone.  Its  anatomic  relations  are  very  important.  Its  anterior 
border,  beginning  above,  is  the  superficial  landmark  for  the  location 
of  the  facial  and  spinal  accessory  nerves  and  of  all  the  sti'uctnres  which 
occupy  the  carotid  triangle,  such  as  the  jugular  and  adjoining  lymph 


sriu^icAi.  AXAToNn   (II'   riir.  riiAnvw,  I.All^^■x,  anh  ni.ck.  Si) 

iioilfs  111'  tho  iqipe'r  ilocp  fcTvical  cliaiii,  tlir  iiiti'iiial  ju.nular  \ciii,  tlio 
carotid  arteries  and  the  various  branches  of  the  external  carotid,  and, 

if  t!ii'\'  arc  dcsii-cd  lo  he  ajiju'oaclu'il  iicar  tlicir  (ii-i^'iii,  tlic  liypou-lossal, 
tlu'  iincniiiou'astrit'.  tlif  syiiipal  lidic.  ami  llh'  i;liissiiii|iaryii:4ral  iicn^es. 
I.nwi'r  ilowii.  it~  anti'iini-  Imnlri-  is  till'  laihlniark  for  the  coimnon  car- 
utiil  and  iiilcnial  .jugular  xciiis,  tin'  (Icsccinlciis  liypo,i;'lo.ssi,  and  the  SU- 
peridi"  and  ivcnrrcnt  lanni<j'eal  nerves.  The  anterior  jinrt  of  the  npper 
extremity  of  tlie  nnuscle  is  covered  by  tlie  parotid  fi;land.  About  one- 
fourth  of  the  way  do-svn  its  anterior  border,  the  sternocleidomastoid 
mnsclo  covers  tho  ])ostorior  belly  of  tlie  din'astric  muscle  as  it  passes 
upward  and  backward  to  its  insertion  into  the  mastoid  process. 

Tlic  Submaxillary  Salivary  Gland  is  situated  just  beneath  the  hori- 
zontal ramus  of  tlic  niaudiblc  near  tlu>  autjle  and  is  ])artially  covered 
by  it.  It  occu])ies  a  triauii-ular  space  w  liicli  i-  luMindid  externally  and 
aliove  by  the  inner  surface  of  the  mandible,  exliinaily  and  below  by 
the  skin  and  fa-eia  as  tlicy  pa-s  rr(!iii  llie  cikjc  nl'  the  Jaw  \n  tlic  ucck, 
and  internally  liy  tlu'  mylnliydid  niusele.  The  ptistcrior  part  of  tlie 
Klaud  also  rests  internally  on  the  hyoglossus,  the  posterior  belly  of  the 
diii'astric  and  the  stylohyoid  niii^cles.  Tt  is  crossed  extenially  by  the 
facial  vein,  \\hile  the  facial  artei'y  )iasses  tliroiiuh  a  uroovc  on  its  ex- 
ternal inferior  surface.  The  posterior  end  of  the  L;laiiil  which  is  really 
the  most  bulky  portion  very  often  reaches  to  the  anterior  edsje  of  tho 
sternomastoid  muscle.  Alonja:  its  upper  border  just  beneath  the  lower 
edj>e  of  the  jaw,  the  submaxillai-y  lynijih  nodes  are  sometimes  very 
closely  associated  with  its  capsule,  so  that  in  niali,>;nant  disease  w'ith 
metastasis  to  tlie  sulimaxillaiy  lympii  nodes  il  is  piobablv  best  to  re- 
move the  salivary  gland,  as  well  as  the  lymph  nodes  in  order  to  be  sure 
that  the  dksease  is  erndica1e(|.  The  siihiiiaxillarv  oi-  Wliarlon's  duct 
leaves  the  gland  from  the  anterior  end  and  i~  often  accomiiaiiied  by  a 
toiiiiucdik'c  ]ii'olonuatioii  of  the  glandular  tissue. 

The  Digastric  Muscle  consists  of  two  bellies,  a  posterior  and  an 
anterior.  The  posterior  lielly  arises  from  tiie  digastric  groove  on  the 
internal  surface  of  the  mastoid  process.  Tt  runs  forward  and  down- 
ward, ])assing  through  the  stylohyoid  innscle,  where  it  becomes  ten- 
ilinous.  This  tendon  is  attached  to  the  upjier  surface  of  the  hyoid  bone 
iiy  a  pulley-like  band  from  the  cen'ical  fascia.  The  tendon  passes  on 
through  this  pulley  and  liecomin.ir  fleshy,  f(U"ms  the  anterior  belly,  which 
is  inserted  int<i  the  low  er  horde  r  of  the  lower  jaw  close  to  the  symphysis. 

The  Stylohyoid  Muscle  arises  from  the  base  of  the  styloid  process 
of  tlie  temporal  bone,  and  after  enclosing  tlie  digastric,  is  inserted  into 
the  body  of  the  liyoid  hour,  lis  course  is  almost  paralh'l  with  that  of 
the  digastric.    These  two  muscles  form  the  p(.sterioi-  iiifcii<ir  boundai'v 


90 


lI'Ki'.AFIXK    sriMIKKV    OK    TIIK    XOSK,    'I' 1 1  KOA'I'.    AM)    KAI;. 


of  tliL'  suhiiiaxilhiry  triaii,L;ic,  ami  ai'c  iinpui-taiit  lainliiiarks  fur  the 
(kH'prr  stnicturi's.  Supciiicial  in  tliciii  will  lie  rdiiiul  llic  aiitci'ioi- 
ili\'isi()ii  lit'  the  tciniKirdinaxiUary  xi'iii,  tlic  j'acial  \('iii,  and  llicir  coiu- 
111(111  trunk  as  it  passes  ddwiiward  and  iiiwai'd  tn  Juiii  tlii'  intrnial  jug- 
ular. 

Facial  Nerve. — In  this  jMisition,  it  is  well  to  boar  in  mind  the  rela- 
tion of  tlic  sn|iiaiiiandilinlar  and  inframamlilnilar  liranclies  ol'  tlic  fac-iid 


Fig.  (JS). 

Dissection  of  tlir  jn's  anserinus  of  the  facial  nerve.  The  dotted  line 
represents  the  iKirnial  outline  of  the  parotid  gland. 

1,  Parotid  gland;  2,  Teniporofacial  division;  :',  Cervicofacial  division; 
4,  Stylohyoid  and  digastric  branches;  .5,  Lyniph  nodes  of  the  upper  deep 
cervical  group;  6,  Temporal  branch;  7,  Malar  branch;  8,  Infraorbital 
branch;  9,  Branches  to  parotid  gland;  10,  Buccal  branch;  11,  Supraniaiidib- 
ular  branch;  12,  Facial  artery;  13,  Iiiframandibnlar  branch. 


nerve.  These  nerves  generally  come  from  a  common  stem,  the  cervico- 
facial. The  inframandibular  branch  passes  down  from  beneath  the  in- 
ferior edge  of  the  parotid  gland  to  snpply  the  platysma  myoides,  and  to 
form  a  communication  with  the  supei-ficial  cervical  nerve  of  the  cervicai 
plexus.     From  its  snjierfieial  position,  this  nerve  is  almost  bound  to 


sri;i;ic.\i,  waiomv  ok   tiik  rii.\i:vN\.  i.\i;vn\.  anh   nkck.  :ii 

1h'  cut  in  llie  upLTatidiis  (ui  tliis  rcyiiiii.  l-"iir1iiii;ili'ly,  ilic  i-rsults  arc  of 
little  consoquonco.  'i'lic  supraiiiaiiililnilar  lnaiicli.  cincr^inu,'  iVnni  !ic- 
iicath  tlu^  i>arotiil  lilaiul,  >iiL:lilly  in  rrmil  nj'  tlic  inriaiiiamlilnihir 
liraucli.  sweeps  rmwanl  and  ilnw  nw  aid  to  I  lie  iiircrinr  ciii^fo  ot"  the 
nKintlil)le,  follows  this  to  the  antci-ior  lionlcr  ol*  the  inasseter  iiinsele, 
and  turniiiu"  slisrhtly  uiiwai'd  supplies  tiic  depressor  ansi-uli  oris,  the 
<lepress(ir   iaiiii    int'ei'ioris,   an<l    tiie   orliii-nlaris   (U'is.     '{"lie   ])(isition   of 


a 


Fig.  70. 

Deep  (liasoctioii  of  tlio  carotid  triiingle. 

1.  Piiiotitl  glaiiil;  2,  IiifranuiiKlilnilar  lirandi  of  facial  nerve;  3,  Sterno- 
mastoid  muscle  reflected;  4,  Spinal  accessorv  nene;  .5,  lTypoglos.sal  nerve; 
C,  Internal  carotid  artery;  7,  External  carotid  artery;  S,  Descendens  1iy])0- 
jllo.ssi;  0,  Common  carotid  artery;  1(1,  Tntornal  .iujjnlnr  vein;  1  I,  Supramandili- 
ular  hranch  of  facia!  nerve;  12,  Po.storior  lielly  of  disiasliic  muscle;  i:i. 
Stylohyoid  nm.sde;  14,  Facial  vein;  lii,  Facial  artery;  l(i.  Anterior  divisioi' 
of  temporonuixillary  vein;  17,  Sulimaxillary  .salivary  ■;land ;  l.**,  Anterior 
belly  of  digastric  nuisclo;  lil.  Lingual  vein;  20,  Temporofacial  vein:  21, 
Intenial  laryngeal  nerve;  22,  Superior  thyroid  artery. 


tliis  lii;nicli  (if  ihc  ]\r\-\r  i>  suiiiew  li;M  \a I'i;! Iile,  ;in(l  oecasii mallv,  just 
after  it  emerges  from  the  jiaiolid  .ulaml,  its  course  is  so  far  down  as  to 
make  it  very  open  to  injury  in  reinovin.n-  the  lymph  nodes  at  the  angle 
iif  the  i;iw.  Cnttini;-  of  this  nerve  is  deiihualde  ;i-  il  p;iralyzes  one-half 
nf  the  hiwcr  hii. 


92  nrr.iiATivT,  sriicKi-.v  of  the  xose,  'rmtoAT,  and  ear. 

Internal  Jugular  Vein. — At  alinid  this  depth  it  is  iiii]iortant  to  re- 
moinhor  tho  ])ositi()n  and  rchitioii  of  the  large  veins  in  flic  neck.  The 
internal  jugnhir  vein  whicli  i.s  a  continuation  of  the  lateral  sinus,  begins 
above  by  a  dilation  called  tlie  Indb  which  occupies  the  posterior  com- 
partment of  the  jugular  foramen.  It  runs  obliquely  downward  and 
forAvard,  tenninating  behind  the  clavicle  near  the  sternum  Avhere  it 
uiiilcs  with  the  subclavian  vein  to  fomi  the  innominate.  At  first  it  is 
behind  the  internal  carotid  arteiy,  but  gradually  passes  around  as  it 
descends  until  finally  it  is  on  the  outer  side  of  the  carotid  artery.  In  the 
lower  part  of  the  neck  it  sometimes  overlaps  it  in  front.  The  right 
vein  is  not  very  closely  associated  Avith  the  artery  at  the  base  of  the 
neck,  whilst  the  left  vein  is  almost  in  front  of  the  carotid  arteiy  on 
that  side.  An  important  tributary  to  this  vein  is  the  common  facial 
vein.  This  latter  vein  is  fonned  by  the  union  of  the  facial  vein  and 
the  anterior  division  of  the  temporomaxillary  vein.  The  common 
facial  vein  crosses  over  the  external  carotid  arteiy  generally  a  little 
below  the  posterior  belly  of  the  digastric  muscle  and  frequently  has 
to  be  ligated  and  cut  to  expose  the  external  carotid  near  its  base. 
Sometimes  the  common  facial  vein  gives  off  at  the  anterior  edge  of 
the  sternomastoid  a  branch  which  may  be  quite  large  and  which  runs 
along  the  antei'iov  border  of  the  sternomastoid  to  the  suprasternal 
fossa  where  it  joins  the  anterior  jugular  vein.  The  internal  jugular 
vein  occupies  the  connective  tissue  slicalli  in  coniiiion  \\ith  the  carotid 
arteries  and  the  jineumogastric  nerve. 

The  Hypoglossal  Nerve  heaves  the  skull  through  the  anterior  con- 
dyloid foramen.  It  arche.-  downward  and  forward  passing  to  the  outer 
side  of  both  the  internal  and  external  carotid  arteries  and  internal  to 
the  posterior  belly  of  the  digastric  and  the  stylohyoid  muscles.  As  it 
crosses  the  internal  carotid  artery  it  passes  below  and  around  the  oc- 
cipital artery.  In  its  course  this  nerve  communicates  Avith  the  pharyn- 
geal branch  of  the  A'agus,  and  sends  a  small  branch  to  the  thyrohyoid 
muscle.  It  passes  foinvard  beneath  the  stylohyoid  muscle  and  external 
to  the  hyoglossus  muscle  just  above  the  hyoid  bone.  In  this  position 
it  is  an  important  landmark  for  an  approach  to  the  lingual  artery.  The 
lingual  branches  of  this  nerve  are  distributed  to  the  hyoglossus,  the 
geniohyoid  and  the  geniohyoglossus  muscles  and  practically  to  all  the 
intrinsic  muscles  of  the  tongue.  The  descendens  hypoglossi,  a  rather 
large  branch  of  the  hypoglossal,  descends  along  the  external  surface 
of  the  carotid  sheath,  though  sometimes  it  occupies  the  interior  of  the 
sheath  and  fonns  Avith  a  branch  from  the  second  and  third  cervical 
nerves  the  ansa  hypoglossi.  Branches  from  this  plexus  run  to  the  omo- 
hyoid, the  sternothyroid  and  the  sternohyoid,  but  it  is  probable  that  the 


;ri;iiiiAi.  .waiomn   ok   tiik  i'iiakvnx.   i.akvnx.  anh  m;ck 


!):! 


iuiUTX  alinll   nf  \\{r>r  lllll>.'lcs  ciillii'S   tlllnuull    lllc   ciTvicnl    llrlAi'S   Illld    lint 

Iliniuuli  the  liyiioiil(»s;il. 

'I'lic  Common  Carotid  Artei-y  ariM-  <>ii  ihr  riulil  >\<\''  "f  tlir  iiim-I< 
iVoiii  tlic  iiiiioiiiiiiatc  artery,  aiid  nri  tlu'  Idt  .-i.l.-  \'v>n\\  llir  ardi  of  ll:.- 
aorta.  Tn  tlu'  nock,  liowovi-r,  tlio  two  arterii's  liavo  prat-tifally  tlio  same 
ri'lations.  It  is  iiiiiK)rtaiit  to  rciiU'iiilxT.  liowi'vor,  tliat  tlio  tlioraoic 
(liiot  i)assos  iiniiiodiatily  luliiinl  tlic  Irft  carotid  artory  just  before 
arcliiiin-  downward  to  ciih  r  tlic  iiiiioiniii.itc  \tiii.  and  tlie  rocnrrent  lar- 
yngeal iiciA'c  has  alirad>  passed  to  tlic  iiinci'  side  nl'  llie  artery  liefore 
liie  artery  enters  the  neck  proper.  (  >ii  the  riulit  side  the  recurrent  hiryn- 
iioal  ner\-e  lies  liehiiid  the  carotid  artery  in  the  h.wer  |>art  of  the  neck. 
At  about  the  lov(d  nf  the  lirst  nwj;  of  the  trachea  the  inferior  tlm'oid 
artory,  a  branch  of  the  thyroid  axis,  |)asses  imniediatoly  behind  the 
conunon  carotid.  The  stornoniastoid  l)rancli  of  the  su]»erior  thyroid 
artory  crosses  over  the  conunon  carotid  alonji'  the  anterior  ed<;-e  of  the 
omohyoid  at  about  the  lovol  of  the  sixth  cer\  ical  \erlelira.  A  line  for 
the  conimon  carotid  is  from  the  n])pei  part  of  the  -teniii<'la\  ii-iilar  ar- 
ticnlatiiiii  ti)  a  point  midway  Itetweeii  the  anule  nt  the  jaw  aiicl  the  tip 
of  the  iiKoloiil  process.  'I'lie  jioiiit  of  lii I'll icat i( m  into  the  two  termi- 
nal branches,  the  external  and  inteinai  caioti<l  arteries,  is  usually  on 
a  level  with  the  up])er  l)ordor  of  the  tli\  roid  caiiila.uc  It  is,  however, 
not  uncommon  for  the  external  carotid  to  he  ,L;iveii  olV  considerably 
hi.uhor  U]),  and  this  anomalous  condition  sometimes  makes  it  difficult 
to  quickly  reacli  tlio  external  carotid  for  lis-ation. 

The  Omohyoid  Muscle  which  crosses  the  common  caiotiil  externally 
consists  of  two  hellies,  the  anteiioi-  and  the  poslerioi'.  It  arises  from 
the  u|iper  horder  of  the  scapula  and  the  suprascapular  liiiamont  and, 
passing  forward  and  sli.ii,htly  ujiward.  i>ccomes  teiidiiiou.s  henoath  the 
stoniomastoid  muscle.  This  part  of  the  muscle  is  called  the  posterior 
belly.  The  auieii(U-  belly  begins  from  this  inlermediaiy  tendon  and 
passes  ohliipicly  ii)iwar<l  and  forward  to  be  inserted  into  the  outer  edge 
of  the  lower  border  of  the  body  of  the  li\oi<|  lio)ic.  The  intermediary 
tendon  is  held  in  ])lace  to  th(>  tii-st  rib  h\  a  proces-  of  the  deep  cervical 
fascia.  The  anterior  lielly  of  the  tiiii>cle  loinis  the  upper  boundary  of 
the  infi'iior  carot'hl  trianule  and  cio^se-  the  cdinnioii  carotid  artery  at 
about    the    Ie\-e|   of   the   cricoid    cartilai^v. 

The  External  Carotid  Artery  is  uMiaily  alioiit  two  and  a  half  inches 
loiiL;'  and  supplier  Mood  to  the  upper  part  of  tiie  ne<-k  and  nearly  the 
whole  of  the  head  and  face,  outside  of  the  cranium.  Its  course  is  gen- 
erally at  lirst  slightly  forward,  then  backwjird,  upward  and  inward,  be- 
hind till'  posterior  belly  of  the  digastric  and  the  stylohyoid  muscles  to 
the  under  surface  of  the  parotid  gland.     It   terminates  near  the  upper 


94  (IIM''.r,ATl\'I'".    sriKM'.li'i'    Ol-    TilK    \(ISK.    'I'llIKiAT,    A  \  1 1    KAII. 

part  (if  llic  iilaiid,  ni'iicrally  liciicatli  it  hut  sonu'linics  in  its  sulisfancc 
by  ili\i(liii,<;-  into  the  internal  niaxillai'v  and  the  suiicilicial  tcni|Miral 
arteries. 

The  Superior  Thyroid  Artery,  tlic  first  Inancli  ol'  llic  cxtcinal 
carotid,  arises  from  the  front  of  tlie  carotid  just  below  the  tip  of 
the  ^Teat  cornu  of  tlie  liyoid  lionc.  The  artery  runs  at  first  forward, 
but  soon  turns  downward,  sending-  1  tranches  to  tlie  laiynx,  sternomas- 
toid  muscle  and  the  thyroid  ^land.  Tn  tlie  be.yinning-  of  its  course  it 
lies  on  the  inferioi-  constrictor  nmscle,  an<l  is  in  \'ery  close  rehition 
with  the  external  laryngeal  branch  of  the  superior  laryngeal  nerve. 
For  a  sliort  distance  after  leaving  the  cover  of  the  sternomastoid  the 
artery  is  directly  under  the  deep  cervical  fascia,  but  lower  down  it  is 
covered  by  the  omohyoid,  sternohyoid  and  sternothyroid  muscles  and 
is  generally  overlapped  by  its  accompayning  vein. 

The  Ascending  Pharyngeal  Artery,  the  second  branch,  arises  from 
the  inner  surface  of  the  extenial  carotid,  almost  opi)osite  the  superior 
thyroid  and  runs  upwards  on  the  constiictor  muscles  of  the  pharynx 
to  supply  the  wall  of  the  iiliarynx  and  the  soft  palate.  A  palatine  branch 
from  this  artery  is  not  a  constant  structure,  but  when  present  takes 
the  place  of  the  ascending  palatine  branch  of  tlie  facial,  and  supplies 
the  upper  ])art  of  the  tonsil. 

The  Lingual  Artery,  the  third  Inanch,  springs  from  the  front  of 
the  external  carotid  just  above  the  superior  thyroid  and  about  opposite 
the  tip  of  the  great  cornu  of  the  hy^oid  bone.  The  artery  fonns  a  loop 
upwards  in  the  first  part  of  its  course,  and  liere,  except  that  it  is  crossed 
superficially  by  the  hypoglossal  nerve,  it  is  covered  only  by  the  skin, 
fascia  and  platysma.  Reaching  the  iiosterior  l)or(k'r  of  the  liyoglos- 
sus  muscle  it  passes  beneath  this  structure  just  above  the  great  cornu 
of  the  liyoid  bone.  It  terminates  as  the  ranine  artery,  and  is  the  chief 
blood  sup])ly  to  the  tongue. 

The  Facial  Artery,  the  fourth  liraneli,  arises  from  the  carotid  im- 
mediately above  the  lingual,  but  i^asses  upward  to  the  inner  side  of  the 
posterior  belly  of  the  digastric  and  runs  forward  and  downward 
through  a  special  groove  in  the  submaxillary  gland  to  the  margin  of 
the  jaw,  just  in  front  of  the  masseter  muscle.  Sometimes,  however, 
after  reaching  the  uppier  border  of  the  digastric  muscle,  it  loops  up- 
wai'ds  until  it  comes  into  close  proximity  with  the  inferior  pole  of  the 
tonsil,  though  always"  separated  by  the  middle  constrictor  muscle. 
After  reaching  the  edge  of  the  jaw,  tlie  facial  artery  passes  just  beneath 
the  fascia  and  skin  to  sujijily  the  various  structures  of  the  face,  tenni- 
nating  in  the  angular  artery  on  the  side  of  the  nose. 

The  Occipital  Artery,  the  fifth  branch,  arises  from  the  back  of  the 


srncicAi.  AXATiiMv  111-   Till'.  nivnvNX.  t.aiiynx.  axi>  nkcic.  :'•> 

i\tcin;il  carnlid  just  liclow  tlic  pustcrini-  liclly  lA'  the  ilii;;is1iir  iiiid  riiii- 
iiiiit!:  ii])war(l  and  l)a('k\var(l  ihhUt  tlic  iidstcrini-  ImHv  iA'  tlie  digastrif, 
it  crosses,  lirst  tlii^  iiitcnial  carotid  artt-ry.  Ilicn  I  lie  iiy|>(>i,d<)ssal  nerve, 
llio  piieuino.iiastric  iiciac,  tin'  internal  jni^nlar  \'ein  and  la^1l>  the  -pinal 
ac-cessory  nerve.  Tin'  liyjiniiho.-al  nerv<'  lioulo  arniind  tiic  ailiTy  Jusl 
as  it  iiranelies  lidin  the  carDtid.  I>y  passin;;-  lietweeii  the  transversa 
jnoeess  of  tiie  atlas  and  the  hase  of  the  >knll.  the  ()cci])ital  artery 
reaelies  tlie  diijastrie  ijroove  of  the  niastnid  pidcess.  In  this  ]iart  of 
its  course  it  is  sepai'ated  iVuni  tin'  xirtelual  artery  liy  tiie  I'ectns  cajiitis 
lateralis  niusole. 

The  Posterior  Auricular  Artery,  the  sixth  Inanch,  leaves  the  back 
of  the  extei-nal  cai'ntid  Just  almxc  tin-  dii^astric  niuscli'  and  jiassincr 
uinh'r  the  ijustcrinr  part  i>\'  tin'  pamtid  u'land  I'uns  hetweeii  the  niastnid 
process  and  extei-nal  anditory  meatus,  wiiere  it  is  in  close  relation  with 
the  postericu'  auricular  iii'anch  of  tiu>  facial  iu'r\e. 

The  Internal  Maxillary  Artery,  the  seventh  l)ranch,  one  of  the  ter- 
minal hranehes  of  the  external  carotid,  hei-ins  liehind  the  neck  of  the 
lower  jaw  and  passes  forward  to  supjily  practically  all  of  the  inteiua! 
structni-es  of  the  face,  'i'he  lirst  part  of  the  artery  is  tdosely  associ- 
ate(l  with  the  auriculotemporal  nersc  and  inteinal  maxillary  vein,  and 
it  lies  between  tin'  sphenoina]nlii)ular  ]i,i;ament  and  the  neck  of  the 
jaw.  Its  second  jiart,  occupying'  the  zy.iidmatic  fossa,  may  run  either 
over  or  under  the  lower  liead  of  the  external  i)tery,u-oid  muscle.  Wlien 
it  passes  between  the  heads  of  the  external  pleiy<>()id  muscle  it  comes 
into  close  relationship  with  the  third  division  of  the  tifth  nen-e.  The 
third  ])art  of  the  artery  luus  hetweeii  the  lower  heads  of  the  external 
)i1ery,i;<)id,  thence  through  the  pteryi;oniaxillarv  fissure  into  the 
sphenomaxillary  fossa.  This  ai'tery  yives  olf  numerous  branches,  one 
of  which,  the  posterior  or  descending-  ])alatine,  runs  downward  through 
the  posterior  palatine  c;iii;il  t<i  the  roof  of  the  nH)uth,  wliere  it  crosses 
forward  beneath  the  mucous  nieiiihraiie  just  inside  the  alveolar  proc- 
ess. It  gives  off  small  branches  which  supply  the  soft  palate  and  anas- 
tomose with  the  asc<'nding  palatine  and  tonsillar  branches  of  the 
facial  and  piolKiMy  with  the  ascending  i)haiyngeal  artery.  Another 
iiranch,  tiie  vidian,  supplies  l)i-anches  to  the  upper  jtart  of  the  j)harynx 
and  to  the  Eustachian  tuiie.  Another  branch,  the  pterygopalatine  su|)- 
plies  the  upper  and  iiack  part  of  tlie  in)se,  the  piiaryngeal  vault  and 
surrounding  structures. 

The  Superficial  Temporal  Artery,  the  eiglitli  liranch,  the  second  of 
the  terminal  branches  of  the  extei'ual  carotid,  begins  in  the  u|)]ier  i)art 
of  the  parotid  gland  Itehind  the  neck  of  the  niiiiidibular,  and,  dividing 


96 


(ll'Kl-.ATIVK    sriKlKKV    OF    TTIK    XOSK,    TIll'.OAT,    A.NH    KAn. 


iiiU)  nil  ;uiti'i-i(ii'  and  iiostt'r'iDr  liraiicli,  supiilicj^  llic  aiiU'rior  half  of  the 
scalp. 

Till'  Internal  Carotid  Artery,  ln\<;iiiiiiiiy  at  tlic  h'\cl  of  tlic  upper 
liordcr  of  the  thyroid  cartilatic,  runs  upward  and  inward  posterior  and 
cxlcnial  to  liie  external  carotid.  Jt  passes  into  the  skull  tlirou,!;li  the 
carotid  canal  of  the  teiii])oral  lione.  Posterior  to  the  arteiy  and  sliuhtly 
iiiternai  are  the  rectus  capitis  anticus  major  innscle,  the  ]ireveiiehral 
fascia  and  the  sympathetic  cord.     The  internal  jn.^ular  \-ein  and  \a,'j,us 


..^      1 


IS 


Fig.  71. 

The  .(-lation  of  the  pahital  tonsil  to  the  vessels  and  nerves  of  the  caro- 
tid triangle.  Portion  of  the  maaidible  has  l.een  reseete.l  and  the  tong-ne 
removed. 

1  Palatal  tonsil  reflected  backward  and  upward  from  its  beil;  2,  U\uhv; 
3  Extej-nal  carotid  aa-tery;  4,  Palatopharyngeal  muscle;  5,  Internal  carotid 
arterv  6  Ascending  phal^^lgeal  artery;  7,  Lateral  pharyngeal  wall  drawn 
inward  and  backward;  8,  Anterior  palatal  pillar  drawn  upward ;  0,  Facial 
arterv;  10.  Lingual  nen-e ;  11.  Cut  surface  of  tongue;  12,  Glossopharyngeal 
nerve-  13,  Hvpoglossal  nerve;  U,  Lingual  artery;  15,  Styloglossus  muscle; 
16,  Superior"  thyroid  artery;  17,  Superior  laryngeal  nerve;  18,  Comnum 
carotid  artery. 

nerve,  while  on  a  plain  posterior  to  the  artery,  are  oenerally  soiuewliat 
external  to  it.  The  spinal  accessor)  and  olossopliaryngeal  n(M-v(\<  for 
a  short  distance  in  the  upper  part  of  the  neck  are  found  liehind  and 
sli-iitly  to  the  outer  side  passing  between  it  and  the  internal  jugvdar 
vein.    Internally  it  is  closely  associated  with  the  wall  of  the  pliarjmx 


sntcicAi.  ANATiiNn    (II'   rill',  rii  \l:^  N\.  i.\i;\nx.  anh   ni.ck. 


!)7 


lull  M'lMiatcil  liy  the  ;iM-riiirii:u  |i|i;n\  iil;i';iI  .•iitrry.  tlic  |iliiii-yimr;il 
plexus  of  voiiis  ami  the  siipcrinr  laryii^f.-il  iicrvc  .Inst  boforc  the; 
artny  nitiTs  tlio  t(Mii|ii)ral  Ikiiic  tlif  Irvatdr  jialati  iiuisi'le  is  fouiul  on 
its  inner  side.  It  is  crossed  extirnally  liy  tlie  hypoglossal  nerve  anil 
the  oeeipital  ami  posterior  anrieular  arteries,  ami  it  is  separated  from 
I  he  external  rarorid  li\  llic  -I  \  lopharyniiciis  an  I  >1ylo.i;los.-ii>  iiinsrlr-, 
the  stylohyoid  lii;anient,  the  glossophaiynucai  nerve,  tiic  pharynncal 
hraneh  of  the  vaiius,  and  some  tine  symiiathetic  twij-'s.  The  dif^astric 
and  stylohyoid  museles  run  external  Koth  to  it  and  to  the  external 
earotid.  The  upjier  jiart  of  the  inteinal  earoiid  in  the  neck  is  covered 
hy  the  i>arotid  irlantl.  As  a  rule  no  iuanches  are  i;i\cn  olT  from  the 
internal  earotid  artery,  while  in  the  neek'. 

The  Pneumogastric  or  Vagus  Nerve  oeenpies  the  carotid  sheath  lie- 
ing  placed  liehind  and  hetween  lirst  the  internal,  then  the  common  car- 
otid arteiy  and  the  internal  jujiular  vein.  Two  ganiilia  are  found  on 
tlie  pneumogastric  nerve  as  it  leaves  the  skull  through  the  .I'ngular 
foramen.  The  upper  and  smaller  one.  the  ganglion  of  the  root,  gives 
oil'  a  meningeal  lu-anch  and  an  auricular  (Ariuilil's  nerve)  hraneh. 
The  latter  generally  communicates  with  the  tympanic  branch  of  tlie 
glossopharyngeal,  also  Avith  the  facial  nerve.  The  lower  ganglion  of 
tlie  trunk  gives  off  the  phannigeal  branch  and  the  superior  laryngeal 
nerve.  The  phaiyngeal  branch  which  iiall\  derives  its  fibres  from  the 
spinal  aceessoiy  nem-e,  nms  between  the  internal  and  external  carotid 
arteries  and  hel]is  in  the  formation  of  the  pharyngeal  i)lexus. 

The  Superior  Laryngeal  Nerve  luus  downward  and  inward  behind 
the  external  and  internal  carotid  arteries  to  the  tiiyroid  cartilage.  In 
its  course  it  divides  into  the  intei-nal  and  exli'iiiai  laiyngeal  nerves. 
The  internal  laiyngeal  lU'rve  gains  access  to  the  laiynx  by  running  be- 
tween the  middle  and  inferior  constrictor  muscle  of  the  |)harynx  and 
tlirough  the  thyrohyoid  membrane.  The  external  laiyngeal  nerve 
passev  ddwnward  u])on  the  inferior  constrictor  muscle  ending  in  the 
i-rieot  hyiiiid  in  the  lower  part  of  the  neck. 

Tlie  Recurrent  or  Inferior  Laryngeal  Nerve  is  a  branch  of  the  vagus. 
I  >ii  the  i-iL;lit  ~i(li'  of  the  neck  it  leaves  the  vagus  as  it  passes  over  the 
sid)clavian  aitery.  It  then  runs  njjward  behind  the  subclavian,  the 
common  carotid  ami  the  inferioi-  thyroid  artei'ii's,  and  liehiml  the  thy- 
roid body.  It  entei>  the  laiviix  liv  passing  beneath  llie  lowi'r  border  of 
the  inreri(jr  ciuislricloi'  muscle.  The  left  rei'urrent  laryngeal  nerve 
leaves  the  vagus  as  it  crosses  the  aortic  arch.  Pa.ssing  around  and 
behind  the  arch  it  runs  ujjward  in  the  interval  between  the  trachea  and 
esophagus.    In  the  neck  its  course  is  similar  to  that  on  the  right  side. 


yO  OPKIIATIVK    sri'.CKnV    of    the    nose,    TIIIIOAT.    AXll    F.AK. 

Till'  Spinal  Accessory  Nerve  dhidcs  in  Ihc  ju.L^ular  foiiinu'ii,  tlie 
accessory  iiorfnui  of  the  nerve  joining  the  vnniis.  Tlie  spinal  portion 
■of  the  ncrNc  then  lams  downward  into  the  neck,  occupying  at  first  the 
interval  lictween  the  external  carotid  artery  and  the  internal  jugular 
vein.  It  iiuis  downward,  outward,  and  then  crosses  obliquely  back- 
ward over  the  vein  to  rcaeli  the  internal  surface  of  the  steniomastoid 
muscle.  It  then  pierces  this  muscle,  sending  fibres  to  it,  and  enters 
the  posterior  triangle  of  the  neck  near  the  exit  of  the  cervical  plexus. 
Crossing  the  posterior  triangle  it  su])plies  the  trajx'zius  muscle  entei'- 
ing  on  its  inner  surface. 

The  Glossopharyngeal  Nerve  leaves  the  skull  through  the  jugular 
foramen  and  arching  downward  and  forward  passes  between  the  in- 
ternal carotid  artery  and  the  internal  jugular  vein,  and  below  the  ex- 
ternal carotid.  It  passes  around  the  outside  of  the  stylopharyngeus 
muscle  and  the  stylohyoid  ligament  and  below  the  hyoglossus  muscle, 
terminating  in  the  tongue.  It  innen'ates  the  stylopharyngeus  muscle 
and  sends  important  branches  to  the  pharyngeal  plexus.  It  also  sends 
a  few  direct  fibres  to  the  mucous  membrane  of  the  pharynx  and  another 
branch  to  form  the  tonsillar  plexus  which  supplies  the  mucous  mem- 
brane covering  the  tonsil  and  the  immediate  surrounding  region. 

The  Pharyngeal  Plexus  of  nerves  is  made  up  of  branches  from  the 
glossopharyngeal  and  the  pneumogastric  nerves  and  the  superior  cer- 
vical ganglion  of  the  sympathetic. 


(•|i.\rTi:K  III. 
Tin:  SlRlilCAL  ANATOMY  OF  THH  HAR. 

Bv   (iKoiiiiK    I'l.   Sii  \Mi;\n;ii.    M.    I  >. 

Introduction. 

Xdwlicrc  is  siii\:ivry  iiinrc  iU'iicimIi'IiI  mi  ;i  kimw  lc(li:r  of  .■inalniiiic 
<l('t;iils  lliaii  ill  the  ()iifralinii>  ii|iiiii  llir  car.  In  tin'  li'Mi|Hiral  liuiu.'  arc 
Icicati'il  a  iiuiiilicr  nl'  iiii]inrtaiil  aiiatdiiiic  >tnictiirrs  a  >lii:lit  iii.jui'y 
of   wliicli    may   1h>    fnllnwcl    liy    M'l'idiis    rcsiili>.      The    fact    thai    tlic^^o 

.'<tiaK-tUI-C.'^    clK-rdacil    tUl    the    Held    nf    (ipfratiuli    wllicll    lirs    ilrcp    ill    lll(» 

temporal  bone  makes  the  (hiiiucr  I'roiii  injury  nnich  s^-reater  than  when 
the  opt'ratinii'  is  done  in  soft  >t  nictiii o. 

The  perl'ei'iiiiL;  uf  aural  -uriicry  is  the  dirert  result  nl'  the  iiinih'rn 
tt'iK.k'ney  to  specialization  wliieli  has  made  it  jiossihU'  tor  the  olohii;ist 
to  master  the  complicated  anatomy  of  this  region.  The  first  i)roliieni 
for  the  snrii'eon  ■who  woiihl  nn(h>i'tal<e  the  ojid'ations  on  tlu'  eai'  is  to 
master  tlie  (h-tails  <i\'  the  anatomy  nj'  this  rei:i(ui.  Tiiis  cannot  he  ac 
(piired  from  text  h(Hik>  imr  is  tiiis  kimwled^c  readil>  gained  hy 
attempt-  to  do  tiiese  operations  on  the  eada\er.  .\  tlior<mL;li  i:rasp  of 
the  comjilicated  anatomy  of  the  tempdral  hmie  is  hest  ae(piirei|  liy  a 
study  of  ])reparatioiis  ma<le  e-pei'lally  tn  show  this  (U-  that  rehitioii. 
The  knowledge  comes  tliroiigii  the  actual  niakiiiL;-  and  haiidiiiii"'  of  such 
]ire|iarations.  The  most  tiiat  can  he  hoped  frum  a  chapter  on  the  sur- 
gical anatomy  of  the  ear  is  to  point  out  the  \"ari(uis  relation-  which 
must  lie  ke|it  in  mind  wiien  niKhu-taking  the  surgery  of  thi-  region  and 
to  emphasize  these  relations  li>'  drawings  from  aetnai  preparations. 
"^Phe  stud>'  of  such  a  chapter  can  in  no  sense  ser\-e  as  an  adeipiate  suh 
stitute  fiu'  the  actual  liandlim:'  of  anatomic  preparations,  which  after 
all  is  the  only  way  of  aeipiiriiii;'  real  anatomic  kiiowled-e.  it  is  ho|u'(l 
that  thi-  ciiapter  nia\  -er\-c  to  call  the  attention  of  the  lieginner  to  the 
more  important  surgical  relation-  of  ihi'  temporal  hone  >o  that  with 
this  as  a  guide  he  may  work  <iut  f(U'  him-elf  tlu'se  relations  from  prep- 
aration- of  his  own. 

The  Development  of  the  Temporal  Bone. 

The  temporal  hone  i-  formeil  from  t  luce  part>,  tlie  pars  jietrosa,  the 
pars   s(|uamosa   and    the   pars   txinpanica,    which    in    the  new-born   are 


100  ()PKi;.\Ti\  K  sri;(;Ki;v  of  tiik  xosk,  tiii;<)AT,  and  kah. 

sliai'p]\'  sc|i;ir;itcil  li\  well  iiiai'kc'il  sutiiro.  (  M'  tlicsc  llic  pdrdus  is  tlio 
most  iiiii'iii'taiit  as  it  contains  the  laliyriiitli  ami  it  is  I'l-nin  the  ]i('ti-oiis 
bone  that  lln'  mastoid  process  d('\('l()ps.  Tlic  1>nipaiiic  Ikhic  in  the 
hcw-Imiiii  is  liut  a  siiallow  curved  rim  contaiiiiiii;-  a  liroovc.  tlic  sulcus 
tymi)aiiicus,  for  llic  attachment  of  the  mendirana  tynipani.  The  rim  is 
incomplete  at  tlie  upper  pole,  the  cleft  fomiing'  the  incisura  tymjianica 
in  wliicli  the  mendjrane  of  Shraimell  is  attached.  The  squamous  bone 
in  the  ne\\-l)orn  forms  the  outer  covering  for  the  recessus  epityinpan- 
icus  (the  attic  and  aditus)  as  well  as  the  outer  covering  for  the  antrum 
tynnpanicum.  The  roof  of  these  chanibei's,  the  tegmen  tym])ani  et 
antri,  is  formed  in  part  from  the  squamous  bone  and  in  juirt  from  the 
petrous.  The  suture  passing  directly  through  the  tegmen  is  quite 
patulent  in  the  new-born.  This  explains  the  ready  occurrence  in  the 
young  of  meningeal  symptoms  in  cases  of  acute  suppuration  of  the 
middle  ear. 

The  outer  surface  of  the  temporal  bone  in  the  new-born  jiresents 
an  ap]iearance  quite  unlike  that  seen  in  the  adult.  The  most  con- 
spicuous dilference  is  the  complete  absence  of  an  osseous  external 
meatus.  The  membranous  meatus  is  connected  to  the  shallow  rim  of 
bone,  the  pars  tympaniea,  in  -wdiich  the  membrana  tynq)ani  is  attached. 
This  close  relation  between  the  membrana  tympani  and  the  mem- 
branous external  meatus  accounts  for  the  occurrence  of  pain  in  a 
young  child  whenever  in  cases  of  acute  otitis  media  the  auricle  is  ma- 
nipulated. In  older  children  this  symptom  disappears  because  the 
cartilage  of  the  meatus  is  separated  by  a  well  developed  bony  meatus 
from  the  area  of  infilti-ation  about  the  attachment  of  the  membrana 
tympani.  Another  peculiarity  in  the  new-born  is  the  complete  absence 
of  a  mastoid  process.  That  part  of  the  petrous  bone  from  which  the 
processus  mastoideus  develops  presents  a  flat  surface  with  scarcely  a 
suggestion  of  a  prominence  from  which  the  process  develops.  A  con- 
s))icuous  suture  beginning  opposite  the  middh'  of  the  posterior  wall  of 
the  tympanum  and  coursing  upward  and  backward  to  a  notch  on  the 
posterior  margin  of  the  temporal  bone  marks  the  union  between  the 
petrous  and  squamous  bones.  (Fig.  72.)  This  suture,  the  petrosqua- 
mosal,  opens  directly  into  the  antrum  tympanicum  and  often  persists 
in  the  adult  as  a  depression  into  which  the  i>erio8teum  penetrates.  The 
persistence  of  the  petrosquamosal  suture  in  children  has  an  important 
practical  bearing  on  the  course  of  antrum  infection  at  this  age  as  it 
permits  of  the  rapid  development  of  a  subperiosteal  abscess.  It  ex- 
plains also  why  a  simple  Wild's  incision  in  an  infant  is  so  much  more 
effective  than  in  the  adult.  A  Wild's  incision  in  an  infant  for  the 
relief  of  a  subperiosteal  abscess  formed  by  an  extension  from  the 


THE  srruiicAi.  axatomv  ok  THK  KAi;. 


101 


Miitnmi  tliriiiii;li  llic  |ictriiMiii;imn>;il  >iiturr  ;iiiuiniils  ol'lfii  tn  the  s;iiiic 
as  a  Srliwartze  oi»oration  in  the  adult  as  it  gives  a  free  opening  into 
till-  antinin.  the  only  pncnnialic  space  dexeloped  at  tliis  au'e. 

I  Ml  till'  oiiliT  sui-racc  u\'  the  lrni|iural  licmc,  ,iu>1  liack  n\'  ]\\r  |i;ii-s 
tyniiiauiea,  at  aliniit  the  junriuni  of  the  middle  will:  the  lower  tliinis  of 
the  i)ostonor  wall  of  the  t\  iiipaiiic  cavity,  is  a  round  opening  for  the 
exit  of  the  facial  ncrxe.  It  is  important  that  this  position  of  the  stylo 
UKistoid  ojioning  in  l  he  iiii'ant  he  kept  in  mind  w  lien  makiuL;-  the  ineisimi 


V 


Fig.  73. 


FifT.  72.  Temporal  l)Oiie  from  iiew-liorn,  showiii};  distinctly  the  throe 
jiarts  which  go  to  make  iip  this  bone:  the  pars  sciuamosu,  pars  tnnpanica. 
pars  petrosa.  Note  the  aljsenec  of  bony  external  meatus  and  the  absence 
of  a  mastoid  process.  The  opening  of  the  facial  canal  i.s  on  the  e.\po.scd 
outer  surface  of  the  temporal  bone.     (Dr.  G.  W.  Boot '.s  preparation.) 

Fig.  7.3.  Temporal  bono  from  cliild  one  year  old,  showing  the  per- 
sistence of  the  petrosquajiiosal  suture,  also  the  beginning  of  a  mjustoid 
l)rocess  which  is  still  too  small  to  cover  the  oix>ning  of  the  facial  canal. 
The  bony  external  auditory  canal  is  beginning  to  form.  The  lower  ante- 
rior part  is  still  entirely  wanting.     (Dr.  G.  W.  Boot's  preparation.) 


for  the  relief  ol'  a  suli]icriiisteal   alisi'ess,   fur  this  im-isidn   nniiht   se\'ei' 
tile   i'aeial   ller\-e. 

In  the  development  of  till'  tciiiporni  hone  after  hirlii  tlu'  two  eon- 
spieuous  ehanges  l)rought  ahout  ;\vr  tin'  foimntion  of  a  mastoid  )iroe^ 
ess  and  of  a  hony  external  niratn-.  'i'lic  processus  mastoideus  de\idops 
lai-u'ely  from  the  jx-trons  hone.  It  is  first  i-eeognizcd  as  a  small  tuhrrde 
at  ahoiit  tile  aL;<'  of  one  yeai'.  (Fig.  ~'-'>.)  its  develo])men1  taki's  i)iaee 
in  two  dii'iM'tioiis,  outward,  that  is  external  to  the  caxitx  of  the  tyni- 
])aiunn,  and  downward  iielow  tlie  cavity  of  the  tyini)anuin.  It  is  the 
develoimient   of   the   jiroeessus  mastoideus   that   causes   tlie   stylomas- 


102  ol'KKA  riV|-,    SfKCKKV    (IF    Tl  1  K    XOSK.    TlinoA-l'.    A  X 1 1    KAK. 

ti)i(l  I'oriiim'ii  to  rcrt'dc  t'l'din  tlir  Mirl'ai'c  nl'  tlic  li'iiipural  lioiir  until  in 
tlio  adult  it  lies  riilly  '2')  iniii.  fi'dni  the  outei'  sui-racc  (if  the  mastoid.  At 
tlio  aye  of  tlu'cc  Ncars  tlu'  mastoid  has  already  assumed  the  shape 
found  in  the  adult  and  the  diiiastrie  i^roove  is  easily  i-eeouiii/.ed.  (Fia'. 
74.)  The  iieti-os(|uamosa!  sutuic  has  usuallx'  been  oliliterated  with  only 
occasionally  a  depression  markiuii'  its  site.  The  extei-nal  l)ony  eo\er- 
h\g  of  the  antrum  is  still  usually  (juite  ])orous. 

The  develojniient  externally  of  the  processus  mastoideus  is  shared 
hy  both  the  sipiamous  and  the  tympanic  bones.  All  three  enter  int(t 
the  formation  of  the  bony  external  meatus.  In  its  de\elopment  the 
tym])anic  bone  forms  a  trough  Avitli  an  oiieniiii;-  above  the  ])osterior. 
This  trough  in  the  adult  forms  the  anterior,  the  lower,  ami  ]iart  of  the 
posterior  bony  meatus  auditorius  exteruus.  The  u]ipei-  wall  of  the  bony 
meatus  is  formed  jjy  a  horizontal  plate  from  the  squamous  bone.  The 
upper  posterior  margin  of  the  external  meatus  is  fonned  by  the  ])ro- 
cessus  mastoideus  and  is  developed  in  part  from  tlie  petrous  ami  in 
part  from  the  squamous  bones.  It  is  this  uptper  piosterior  ])art  of  the 
external  bony  meatus  that  is  occupied  friMpiently  in  the  adtdt  l)y  pneu- 
matic sjiaces,  mastind  cells. 

Meatus  Auditorius  Extemus. 

In  the  new-born,  as  already  iiointed  out,  the  external  auditory 
meatus  consists  only  of  the  cartilaginous  membranous  i)ortion,  there 
being  no  bony  meatus.  In  the  adult  this  cartilaginous  portion  forms 
scarcely  the  outer  third  of  the  canal.  In  the  development  of  the  bony 
canal  the  part  formed  by  the  squamous  and  ])etrous  bones  ]mshes  out 
beyond  that  formed  from  the  tympanic  bone,  so  that  the  anterior  lower 
Avail  of  the  bony  meatus  is  shorter  than  the  njijier  and  |iosterior  wall. 
This  dehcieney  is  jiieeed  out  by  an  extension  from  the  cartilage  form- 
ing the  auiicle.  In  this  cartilage  Avhicli  forms  the  outer  3)art  of  the 
anterior  lower  wall  of  the  external  meatus  are  several  clefts  called  the 
incisuras  Santorini  Avhich  relieve  the  rigidity  of  this  part  of  the  canal 
and  permit  greater  mobility  of  the  auricle.  Through  these  clefts  in 
the  cartilage  a  parotid  abscess  occasionally  discharges  into  the  ex- 
ternal meatus  and  tln-ough  them  a  fnruiKde  in  the  meatus  may  dis- 
cluirge  info  the  region  of  the  parotid. 

Tile  anterior  lower  wall  of  the  bony  meatus  is  formed  l)y  a  thin 
plate  of  bone  which  separates  the  meatus  from  the  glenoid  fosso.  A 
severe  blow  on  the  chin  may  fracture  this  bone  and  drive  the  head  of 
the  mandible  into  the  external  meatus.  The  floor  of  the  external 
meatus  makes  a  decided  curve  downward  at  its  inner  third  fonning 


TUK    SlItClCM.    ANATOMV    <)l'    TIIK    K.VI! 


^m 


Fit;.  71. 
Tpmpoiiil  Iwno  from  cliiUl  three  years  old,  sliowiii};  the  mastoiil  proc- 
ess, the  bony  external  auditory  meatus,  and  ohiiteratioii  of  the  petrosqua- 
mosal  suture.     (Pr.  G.  W.  Boot's  prepaiation.) 


Fig.  75. 
Temporal   lionc   from  child   ten  years  old.     The  adult   eharaeters  of  the 
temporal   lione  are   developed.      Persistence  of  depression  over  the  mastniil 
sliowinff  the  line  of  the  petrosquamosal  suture.     (Dr.  G.  W.  Boot's  prepa- 
ration.) 


104 


Ol'KI'.ATlVK    Srr>GEi:Y   OF   THE    JC08E,    Tlir.OAT,    AXD    EAR. 


tlio  sulcus  ol'  llic  c.xlci'iial  meatus.     (Fi.ii'.  ~'i-)     'I'lu'  uai-rnwcst  jiart  of 
tile  I'xti'rnal  lucalus  is  at  tln'  cntrauci'  of  tliis  sulcus.     'I'lic  sulcus  itscll' 


Fit;-.    7(1. 
Frontal    soction    tlirnui;li    tlie    ;iilult    tfniiionil    lioiio;    the    iiiiterior    part 
viewed   from   lieliiiid.     Sccticui    iiussos  tlinniyli   external   nuatus,   eavuni   t\nn- 
]iani.  and  lalivrintli. 

is  at  times  so  deoii  that  iusects  and  small  foreiiiii  bodies  lodgiiin  in  it 
may  be  completely  out  of  the  lino  of  direct  ins])ection. 

The  upper  postcrii)r  wall  of  the  external  meatus  is  formed  from 
the  mastoid  process  and  this  is  the  only  jiart  of  the  meatus  "wall  en- 


Adult   teniporal   l">n<>   sliowins  the  iiositicin   of   the  antrum   t\-mpanieum 
nd  ma.stoid  cells  ahmo-  the  u|»per  posterior  wall  of  the  external  canal. 


eroached  on  by  mastoid  cells.     These  cells  may  be  found  external  to 
the  supramental  spine  (Fig.  77)  which  is  located  often  somewhat  within 


TirK    SritCICAI,    ANATOMY    111'     11 1 K    K.Al!. 


105 


the  outiT  niariiiii  of  tlic  im-atus.  Tlic  Jiiitniiii  t>  in|iiiiiic!iiii  lir-  iilK)ve 
tlie  upper  ))Ost('rior  wall  of  the  iiu'atiis  just  cxlcrual  to  tlic  un'iiilii-aua 
tyiniKiui  (Fiys.  77.  78.  19).    lu  t-asos  of  acute  mastoid  disease  Avlieu  the 


Fig.  78. 
Iloiizontal  section  tlirough  tlu'  tomporal  l)one  vipweil  from  alxivo.     Spc- 
tion    through   the   external   winal,   (•aviun   tvnipaiii,    laliyrinth   and    interna] 
meatus. 

temporal  l)oue  is  l)einn-  iuvolvcil,  a  periostitis  over  this  poition  of  tlie 
canal  freiiueiitly  results  in  a  liuliiiuu'  or  sinkinn'  of  tliis  part  of  tlie  i)os- 


Fig.   79. 
Section  Uirough  nijustoiil  proc^'.ss  and  exteninl  canal,  showing  pneumatic 
type  of  mastoid  with  the  larger  cells  on  the  peripliera,  also  the  position  of 
the  antrum  above  and  posterior  to  the  external  canal. 

terior  wall.  A  mastoid  aliscc-v  iViMiiicntly  discliariics  into  the  extri'iial 
canal  at  this  point,  hi  case  of  clirouic  suppuration  with  cholesteatoma 
formation  in  the  antrum  the  cholesteatoma  fiecnieiitlv  hreaks  tlirouj-h 


lOG 


IPKIIATIXK    snUlERY    OF    THE    XOSE.    TIIIIOAT,    AXD    EAR. 


into  tlu'  cxtcnial  niriiliis  at  this  jiniiit.  <  )u  the  (itlicr  liaml  it  slimild  \)v 
i-ciiU'ii'.li('i-('(l  that  a  I'liniiicic  hjcatcd  ah)ii_ii'  the  jiostcrioi-  wall  (if  thf 
luratus  may  be  coiirused  with  a  inasloid  aliscess,  since  in  addition  to 
producing  a  bulging  of  this  waU  of  the  canal  it  is  often  associated  with 
an  infiltration  and  edema  over  tlu'  mastoid  process  with  dis])lacenient 
forward  of  the  auriele,  smdi  as  a  mastoid  ahscess  pi'oduees.  '^I'he  rela- 
tion of  the  facial  canal  to  the  upper  and  posterior  walls  of  tlie  external 
meatus  is  of  great  surgical  importance  especially  in  doing  the  radical 
mastoid  operation.  The  inner  rim  of  the  upper  wall  of  the  external 
meatus  lies  directly  over  the  facial  canal  from  the  point  where  the 
nerve  eiitei-s  tlie  tympanum  in  front  of  the  oval  window  until  it  begins 
to  curve  downward  toward  the  stylomastoid  opening.     (Figs.  76  and 


Section    through    temi)Oi'iil    lione,    showing   the    lelation    of    the    facial 
canal  to  tlic  fenestra  vestilmli   and  of  the  horizontal  canal   to   the  antrum. 


80.)  In  this  part  of  its  course  the  facial  nerve  is  covered  by  an  ex- 
tremely thin  shell  of  bone  in  which  dehiscence  frequently  occurs.  From 
the  point  wdiere  the  facial  canal  turns  downward  until  it  emerges  from 
the  stylomastoid  foramen  it  lies  in  the  hone  \vlii(di  forms  the  posterior 
wall  of  the  bony  meatus.  ^Vt  the  jioint  where  this  canal  enters  the 
posterior  wall  of  the  liony  meatus  just  ]iosterior  to  the  oval  win- 
dow it  lies  on  a  level  with  tlie  inner  wall  of  the  tympanum.  As  it 
passes  downward  it  lies  out  fnrtlier  and  further  along  the  external 
meatus  so  that  at  the  level  of  the  floor  of  the  tympanum  the  canal  lies 
several  millimeters  external  to  the  inner  wall  of  the  tympanum.  (Fig. 
80.)  Again  the  relation  of  the  facial  canal  to  the  external  meatus  is 
such  that  where  it  enters  the  posterior  wall  of  the  meatus  near  the  up- 
per part  of  the  tympanum  it  lies  close  to  the  meatus  wall  but  as  the 


TIIK    SllKIICAl,    AXAIiiM  V    ol'     IIIK    KAII. 


107 


canal  jiasscs  (k)\vii\\aril  il  recedes  rmlhei-  ;iii'l  nii-tlier  rroiii  the  Jiieatiis 
until  at  tlic  lovol  of  tlie  tlimr  nl' the  t\nipaiiuiii  il  lies  several  niillinu'tors 
liosterior  ti)  the  ex1etu;il  nuatus.     (Figs.  SU  and  SI.)     These  relations 


neceftsua  B^iTvMPANiCua 


Fijf.  81. 
Section  thioiigli  tenii>oiMl  liono,  exposing  tlio  facial  canal. 

of  the  facial  canal  to  tlie  jio.stcrioi'  wall  <ii'  the  exlerna!  meatus  make  it 
necessary,  when  performing-  the   radical   mastoid   (ipiM-ation,  to  leave 


1h 


i  CAROTICUS 


i'ii;.  S-. 
Ailiilt    lempoial    Ixine,    sliowing    anatomic    relations    al'ler    a    coniplele 
t  viii|/;inoiTia>itoi(|  exenteration. 

staiiilini;-  a  jiart  «\'  the  posterioi-  \v;dl  nf  ihe  c.-iiial.     iVla.  Si'.)     On  tli,. 

"til. 'I-    li;i||d    it    iv    |,n»il,l,.    In    IVlimM-    IJlr    |,m|m,.    nf    |„,1|,.    j  V  i  ]  |  m'    in    front    of 

the  facial  ciiiial  which  >e|iai-ates  the  canal  frnni  ihe  iiicatn<. 


108 


OPEHATIVE    SriICEKY    OF   TIIK    XOSE,    TIIIIOAT,    AND    KAU. 


The  Processus  Mastoideus. 

The  mastoid  process  is  surgically  the  most  important  i)art  c)f  the- 
temporal  lioue.  Most  of  the  serious  complications  arising  in  the  course 
of  snpiijurative  middle  ear  disease  develop  from  disease  of  this  proc- 
ess and  the  operations  undertaken  for  the  relief  of  these  com]ilications 
begin  with  an  exenteration  of  the  mastoid. 

The  outlines  of  the  mastoid  process  present  a  cone-shaped  appear- 
ance, the  apex  of  the  cone  pointing  downward,  the  base  of  the  cone 
uppermost.  The  size  in  the  adult  is  not  constant.  The  outer  surface 
is  more  or  less  rounded  or  flattened  deiiending  hu-gely  on  the  size.    In 


Fig.  S3. 
Ailult    tpmpoial    hone,    sliowing-   tlic   typii-al    relatinu    of    tlic   liuea    tem- 
poralis  extending   in   a  lioiizontal   direction   liack   from   the   external   canal. 


the  well  developed  process  the  outer  surface  is  more  rounded  while  in 
the  small  process  the  surface  is  more  flattened. 

The  markings  on  the  outer  surface  of  the  mastoid  process  are  of 
importance.  They  serve  as  a  guide  in  making  an  opening  into  the 
antrum.  The  base  of  the  mastoid  is  marked  off  by  a  horizontal  ridge, 
a  continuation  of  the  root  of  the  zygoma.  This  is  known  as  the  linea 
temporalis  and  is  constant  although  not  developed  as  prominently  in 
some  cases  as  in  others.  The  linea  temporalis  risually  extends  directly 
back  from  and  on  the  same  plane  with  the  root  of  the  zygoma.  (Fig. 
83.)  It  lies,  therefore,  a  little  above  the  external  meatus.  In  some 
cases,  however,  it  curves  down  around  the  upper  posterior  margin  of 


TllK    SntC.lCAr.    ANATOMY    (IT    TIIK    KAl! 


10!) 


tlic  external  iiiejitus  juiil  takes  its  liorizuntnl  (■(iiii>e  iVdiii  almul  tlic 
middle  (if  tlio  oi)eniiij;-  o\'  the  cxIiTiial  niralus.  (  Fi;;-.  84.)  In  otlior 
eases  the  linea  teiii])ornlis  takes  a  >liai|.  eni\f  upward  immodiatoly 
liaek  (ifllic  in>|ii'r  |j<).-trriiir  niai'uiii  i<\'  Ilir  external  niealu-.  I  l-'i;;'.  S."). ) 
It  is  iiuiiorlaiit  tn  nink'rstand  these  \ariali<ins  sinee  tiiis  i-idi;-e  ul'ten 
serves  as  a  guide  in  opening'  the  antrum  and  as  a  lamhnark  indieatiiig 
the  lino  of  separatinn  hi'tween  the  mastoid  and  the  middle  hrain  fossa. 
In  keeping  below  tlie  linea  temiioralis  ulien  ()i)ening  the  mastoid  proc- 
ess there  slionld  be  no  danger  of  entering  tiie  middle  fossa.  The  eases 
in  which  the  linea  tempoi-aiis  takes  a  sharp  eurxc  upward  just  back 
of  the  external    meatus   are   exeeiitious.      Mere   the    middle  fossa  can 


li-.  84. 
-Vdult   tpmpoial   Ixine  showing  the  linea  tpniporalis  nialiing  a  mailxed 
emvp  down  along  tho  posterior  liorder  of  tlie  extprnal  n\oatus  before  turn- 
ing baclswaril.     (.\nat()nii(',  variation.) 


be  readily  entei-ed  l)y  chiseling  directly  inward  from  Iteneath  this 
ridge.  As  a  guide  for  liiidiug  the  antrum  the  linea  temporalis  can 
usually  be  relied  on.  'I'he  opening  is  made  innuediately  below  the 
ridge  (piite  close  to  the  meatus,  and  tlii'  direction  of  the  external 
meatus  followed  until  the  antrum  is  reacln d.  There  is  but  one  tyiie 
of  process  in  which  this  method  could  fail  to  lead  to  the  antrum. 
This  is  wlien  the  linea  tempo|-alis  cnrxcs  down  along  the  pos- 
terior margin  of  the  exteinal  nn^atus  liefdie  coursing  bacdcward.  (Fig. 
84.)  In  these  cases  the  opcnin.;  made  into  the  mastoid  as  indicated 
could  readily  nuss  the  antrum  and  miuht  lead  to  an  injury  of  the  facial 
nerve. 


110 


OI'KnATIVK    srUdKllV    OF   THK    XOSE.    TIIIIOAT,    AXD    EAP,. 


Another  constant  lantlniark  on  the  oiiliT  sniTacc  nl'  the  Icniiioral 
bone  is  the  s|iiiia  supranicatnni  locatcil  at  llic  upiicr  iiostcrior  margin 
of  tho  cxlcrnal  meatus.  (Figs.  74  ami  77.)  This  is  a  small  rong'henod 
area  for  tlie  atlacliment  ot"  the  superior  li.t^ament  of  the  anricle.  The 
size  of  the  spine  \aries.  It  is  usually  <|v;ite  t'onspit'xu)us  but,  especially 
in  children,  it  may  be  so  small  as  to  escape  detection.  As  a  guide  in 
opening  the  antrum  it  can  always  be  relied  upon  as  its  position  at  the 
upper  posterior  margin  of  the  external  meatus  is  constant.  Tbe  an- 
trum, which  lies  some  distance  out  along  the  upper  posterior  wall 
of  the  external  meatus,  is  readily  reached  by  making  an  opening  in  the 
mastoid  just  back  of  the  supremeatal  spine  and  following  the  direction 
of  the  external  meatus.    To  lay  off  an  imaginarv  triangle  in  this  local- 


^^ 


Fig.  85. 
Adult  tpmporal  Ijoin^  showing  the  linea  temporalis  making  a  curve  up- 
ward at  the  posterior  margin  of  tlie  external  meatus.     (Anatomic  variation.) 


ity  before  making  the  opening  into  the  antrum  would  only  eomplicate 
the  situation  and  lead  to  confusion  in  the  mind  of  the  beginner.  The 
simplest  method  of  finding  the  antrum  when  the  sui)rameatal  spine 
can  be  recognized  is  the  direction  given  al)ove.  In  all  cases  in  which 
the  spine  cannot  lie  made  out  no  difficulty  will  be  experienced  in  locat- 
ing the  antiimi  if  it  be  kept  in  mind  that  this  cavity  lies  above  the  upper 
posterior  wall  of  the  external  meatus  a  shoi't  distance  external  to  the 
drum  membrane.  The  opening  in  the  mastoid  should  be  made  close  to 
the  external  meatus  just  below  an  imaginaiy  line  passing  through  the 
upper  margin  of  the  external  meatus  and  the  occipital  protuberance. 
If  the  opening  follows  closely  the  direction  of  the  external  meatus  one 
cannot  fail  to  find  the  antrum  if  that  cavity  has  not  been  completely 


TIIIC    sriKilCAl.    AXATdMV    OF    TIM.    I'.AI;. 


Ill 


oMitcrati'ij,  as  it   may  lir  in   rare  casi's  nl'  clirdiiic  supiniralidn   n\'  ihc 
iiiiiMlc  car. 

<Mli('i-  iiiarkiiijis  on  tlu'  outer  surracc  of  liic  inastoitl  ai'c  tlu'  opcii- 
iui;-  for  tlu'  emissary  mastoid  vein,  the  tympanomastoid,  ami  tlir  jidro 
s(piamosal  sutures.  Tlu'  ojx'irmir  of  tlie  cmissaiy  mastoid  vein  is  along 
the  posterior  margin  of  lln'  ma>1oid.  (  I'ig.  S4. 1  It  frequently  repre- 
sents a  point  of  increased  tenderness  in  cases  of  tliroiiiliosis  of  the 
lateral  sinus.  The  location  of  tiu'  oj)ening  should  he  kept  ia  mind  Avlien 
operating  on  mastoid  cells  located  along  the  posterior  mai'gin  of  the 
process.  The  tympanomastoid  suture  is  seen  along  the  posterior  mar- 
gin of  the  external  meatus,  ll  marks  the  separation  between  the  part 
of  tlu'  ]iosterior  wall  of  the  meatus  fonned  fi'om  tlie  tympanic  lione  and 


Fig.  8(5. 
.Section   tluoiigli    mastoid    process,    jiiitiiini 
nl.     (Pneiiniatie  tj-pe.) 


tvinp: 


that  formed  from  the  mastoid  iirocess.  Tlie  petrosqunmosal  suture  is 
well  marked  in  the  young  child  hut  is  usually  (piile  ohiiteraleil  in  the 
adult. 

The  mastoid  jirocess  in  the  adult  usually  contains  ])neumatic 
spaces  which  communicate  with  the  antrum  and  are  known  as  mastoid 
cells.  In  the  new-born  there  is  an  absence  of  a  mastoid  process  and  of 
mastoid  cells.  The  antrum,  wliieli  is  in  reality  part  of  the  tympanum 
and  is  known  as  the  autriuu  tympauicum,  exists  in  the  new-born.  As 
the  mastoid  process  develops  pneumatic  spaces  develop  and  as  a  rule 
eom]iletoly  fill  the  ju'oce.ss.  (Figs.  79,  8(i,  87.)  These  cells  often  extend 
lieyon<l  the  idiilini's  of  the  mastoid  process  forward  into  the  root  of 
tlie  zygoma  and  jjosterior  into  the  occipital  bone.  Tlie  cells  lying  near 
the  antrum  are  as  a  rule  small  in  size.     The  cell.>  occupying  the  tip  of 


112 


orKiiATivK  si'i;i;i;i;v  of  tuk  xose.  tiitoat,  and  kai;. 


tlu'  mastoid   and   thost'   lyiiii;'  aloiii;-  llic  posterior  iiiar,i;in  arc  usually 
niucli  laru'cr.     (Figs.  7!>,  8(),  87.)    In  Figs.  88  and  81)  is  shown  an  iinusu- 


Fig.  S7. 
Pncnmuitic  type  of  niastoiil.     Larger  eells  arranged  along  the  periiiliery. 

ally  large  mastoid  cell  outside  the  mastoid  process  lying  internal  to 
the  digastric  groove.  Such  a  mastoid  cell  is  especially  dangerous  be- 
cause in  the  first  place  a  suppuration  here  could  produce  no  symptoms 


Fig.  SS. 


Fig.  S9. 


Figs.  88  and  89.  Soeticiii  tlirough  temporal  liene.  Section  passes 
through  antrum,  vestibule  and  inteiunl  meatus.  Large  pneumatic  cell  de- 
veloped internal  to  the  digastiic  groove.     (Anatomic  variaticui.) 

over  the  outer  surface  of  the  mastoid  and  in  the  second  place  such  a 
cell  might  readily  escape  detection  when  operating  on  the  mastoid 


THE  srncicAi-  axato.mv  ok  tiik  kai:. 


11:; 


])i-ocoss.  The  iiiasloid  ccIIn  ;i11  i-dimiiuiiicalr  witli  the  aiitiiiiii  and  al- 
Ilioiiiili  till'  walls  sc'iini-aliiiL;-  adjoiiiinn'  cells  usiialiy  sliow  deliisccncc's 
itIIs  may  retain  tlieir  own  openinus  leadini;'  to  the  anti'iun.  In  this 
way  it  is  possible  for  a  largo  cell  at  llic  tiji  of  the  mastoid  to  commnni- 
cate  with  the  antrum  tlirong'h  its  own  cliannri  and  without  commuui- 
catinti'  with  ad.joiniui;'  cells.  This  condition  may  oxplain  the  occnrreni'i' 
of  an  isolated  abscess  in  the  tip  of  the  mastoid  process. 

The  process  of  pnenniatization  of  the  mastoid  is  often  incomplete 
so  that  mastoid  cells  are  fornu'd  in  but  a  ])art  of  the  mastoid.  In  such 
cases  the  cells  are  located  close  to  the  antrum  while  the  tip  of  the  proc- 
ess and  the  posterior  margin  are  free  fiom  air  cflls.     (Figs.  80,  90,  91.) 


Fig.  90. 
Soctioii    tlir<>ii<;li    ti'ni])(ii  al    bone,    sliowiiiir    relation    of    tlic    horizontal 
canal  and   facial  canal   to  the  middle   oar  cliambers;    also   relation   of  tlio 
carotid  and  bulbar  jugularis  to  the  c^avum  tympani. 


In  other  cases  no  mastoid  C(■ll^■  whatever  exist.  (Figs.  92  and  9;].)  Here 
tlie  process  is  tlatter  and  smaller  tiian  normal  and  the  size  of  the  an- 
trum also  is  quite  small.  In  other  words  the  whole  impression  one  gets 
tVom  an  examination  of  this  type  of  mastoid  is  that  of  an  undevelo])ed 
infantile  condition.  It  is  this  type  of  mastoid  process  that  is  found  in 
cases  of  chronic  suppurative  otitis  media  dating  from  eai'ly  childhood. 
Air.  Cheatle  interprets  these  facts  as  indicating  that  cases  of  acute 
purulent  otitis  media  are  more  inclined  to  become  chronic  when  occur- 
ling  in  the  non-jnieumatic  (yjje  of  mastoid.  Others  are  inclined  to  be- 
licvr  that  the  lack  of  j)n('uniatizati(m  in  such  cases  is  itself  the  direct 
result  and  not  the  cause  of  the  chronic  suppuration.  The  suppuration 
lieginning  in  early  childhood  before  the  development  of  the  mastoid 


lU 


OPKKATIVK    sriICKKV    (IK    Tl  1  K    XliSK,    •nil'.DAT.    AXI)    EAH 


has  progressed  very  far  liiiulers  its  I'nrtluT  (IcvcloiJUR'nt;   tlie  result 
being  these  cases  of  (•oini)lete  absence  of  mastoid  cells.    This  condition 


-J-^r    'V"^  •■'E""^   .JDITOSPUS   EXTEBNUS 


Fig.  91. 
Soctiou    tliiousli    the   mastoid    process,    showing    Imt    ]!artial    ])noiimati- 
zatiou.     A    few   small    mastoid    tclLs   near   the    antrum    are    all   that    have 
formed. 


Dipltttic    type    of    niustoid.      C' 
Antnmi  tnnpanicum  contracted. 


t     |iiii'iiniatic>    spac 


slionld  not  be  confused  with  tlie  process  of  osteosclerosis  or  hanh'uing 
of  the  bone  surrounding  as  a  rule  a  cholesteatoma  fomiation  in  the  an- 


Tin:    SlTiGICAL    ANATOMY    OI"    TIIK    KAU. 


U.'l 


(nini.  The  iiiof  of  tlio  mastoid  is  a  tliin  shell  of  lionc  which  separates 
ihi'  aiitniiii  and  tiic  mastoid  cell-  riniii  the  middli'  lii-;iiii  I'cissa.  Over 
the  antrum  it  is  t-alU'd  the  te^riien  antri.  Dehiscence  in  the  hone  t're- 
([ueiitly  exists  so  that  only  the  lininij  of  the  mastoid  cells  and  the  dura 
separates  the  cells  from  the  hrain  cavity.     (P''i,i;s.  77,  90,  94,  95.) 

A  luimher  of  im])ortant  structures  come  into  close  relation  \\itii 
tlie  mastoid  pideess.  The  siunmiil  eur\e  u\'  ihe  lalerai  sinus  lies  in- 
ternal to  this  process  and  encrnaches  iiiuie  nr  less  on  spaces  of  the 
mastoid.  (Fig.  82.)  The  distance  separalinn'  this  sinus  from  the  pos- 
terior wall  of  the  external  meatus  varies  in  ditTerent  individuals.  Usu- 
ally tliere-is  ample  space  between  the  sinus  and  the  posterior  wall  of 
tiie  meatus  to  permit  of  a  Avide  opening  into  the  antrum.  In  other 
<'ases  the  sinus  lies  so  close  to  the  meatus  wall  that  the  opening  into 


Fig.  9.3. 
Section  tlii()iiji;li   ailult  temporal   lione,   sliowius'  i>('vsistpiu' 
t^-pe  witli  abscncp  of  pneumatic  spaces  in  tlie  inastoiil.     Tlie  i^ 
horizontal  and  facial  eanals  to  the  middle  ear  spaces. 


i>   of   infantile 
■lations  of  the 


tlie  anlium  has  to  l)e  made  by  working  along  tlie  n])per  posterior  wall 
of  the  meatus  instead  of  posterior  to  the  suprametal  spine.  The 
location  of  the  sigmoid  curve  is  usually  the  same  on  both  sides.  The 
important  relation  of  the  facial  canal  to  the  mastoid  has  already  been 
discussed.  It  is  important  In  remeiiilier  tiiat  mastoid  cells  may  develop 
in  close  proximity  to  tiie  facial  canal  and  that  these  cells  may  lie  deejier 
than  the  facial,  that  is  inteinal  to  it.  The  facial  nerve  is  most  readily 
injured  in  its  course  through  the  tyni|ianiini  nr  at  the  ])oint  where  it 
makes  the  bend  downward  tdwanl  the  stylmnastoid  n]iening.  (Figs. 
77,  80,  81,  90,  92,  94.) 

The  horizontal  semicircular  canal  forms  a  ]ii(iininenri'  in  the  floor 
"f  the  antrum  where  its  liar<l  i\niy  like  capsule  can  leadily  be  recog- 
nized, when  opening  the  anlinni,  by  its  smooth  glistening  appearance. 
Its  position  is  such  that  sin  mi  Id  tlie  cavity  of  the  antrum  be  mistaken 


116 


iii'i:i;a-ii\k  srj;(;Ki;v  m-  •i'iik  \( 


■niKdA'l'.    A  Nil    KAIl. 


for  a  maaloid  cell  a  single  slmkc  df  the  cliisei  in  an  altcnipl  to  jicnc- 
trate  further  mig-lit  readily  open  llie  eanal.  Its  position  in  a  measure 
protects  the  facial  nerves  from  injury  wlien  (ip(>rating  on  Ihe  mastoid, 
for  its  hard  ca]isnle  foi'ms  a  partial  iMiveriiig  Inr  llie  facial  eanal  just 
back  of  the  oval  window.  (Figs.  SO,  !»!),  !I4,  '.'.").)  The  superior  semi- 
circular canal  encroaches  at  times  on  the  anteridi'  inner  wall  of  the 
antrum.  (Fig.  96.)  In  antrum  disease  it  is  jjossible  for  an  erosion 
into  the  superior  canal  to  occur.  This  canal  is  not  exposeil  to  injury 
in  operating  on  the  mastoid  as  is  the  horizontal. 


Section    tliroHgii    aduU    teiniii)i;il    bo: 


carotid  to  the  eavum  t\niii)aiii 
sus  epitympaiiicus. 


)iie,    sliiiwins'    tlic    lelatinus    nf    tlic 
tructiHcs   ill  the   ticior  of  tlie  leces- 


Cavum  Tympani. 

Anatomically  the  tympanic  cavity  forms  but  a  |)art  of  a  larger 
cavity  Avhicli  includes  the  antrum  tympanicum  and  the  passage  between 
these  two,  the  recessus  epitympanicus.  (Figs.  80-95.)  Pathologically 
also  these  chambers  should  be  considered  together  as  they  are  usually 
involved  in  the  same  process.  The  division  of  the  passage  way  from 
the  tympanum  to  the  antrum  into  two  parts,  an  attic  and  aditus,  is  not 
feasible  anatomically.     (Fig.  95.) 

The  inner  wall  of  the  tympanic  cavity  is  formed  largely  by  the 
capsule  of  the  labyrinth.     The  first  turn  of  the  cochlea  produces  a 


TIIK    sniCICAI.    ANATOMY    Ol'    Till'.    KAI:.  Ill 

proiiiineiico  just  pd-sti'iior  to  tlio  rciiti-r  to  wliicli  tlio  trim  ))n)iiioiituiy 
is  given.  Just  above  the  ]irouuintory  is  an  oval  opening  into  the  vesti- 
bule of  tlio  Inliyi-iulli  calicd  the  fenestra  vestibuli.  Tliis  is  the  oval 
wiiuliiw  in  wliicii  llic  I'ooi  |il;ite  of  the  stajies  is  jiltaclicd.  The  "win- 
dow itself  is  at  tlu'  liottoiii  of  a  dr|irrs>iini  out  ol'  wliicii  oidy  the  head 
of  the  stapes  ami  a  suiali  part  nf  the  ciuia'  projrct.  dust  posterior  to 
the  promontory,  lying  l)\it  a  I'oiiplc  of  luilliuu'tt'rs  from  the  oval  win- 
dow, is  the  oiH'uing  into  tlif  lirst  turn  of  the  eochlca  called  the  fenestra 
cochlea'.  This  is  the  round  window  coxcrcd  o\i'r  liy  a  iniMnhrane  which 
separates  the  tympaniuu  from  the  scala  tympaui.  Directly  posterior 
to  that  part  of  the  promontory  which  separates  the  oval  fi-om  the  louud 
windoAv  is  a  de])rcssiou  often  extending  under  the  canal  for  the  facial 


Fig.  95. 
Section    tliroufili    mastoid,   ca\^lm    t_viii])ani.    tulia   auilitiva,    sliowiii<; 
lavfie  tiilial  coll. 


nerve.  Tliis  depression  i.-  known  as  tlie  sinus  tympanicus.  It  is  diffi- 
cult to  smooth  out  this  pocket  when  perfonning  the  radical  mastoid 
operation.  A  eons^iicuous  marking  ou  llie  inuer  wall  of  tlie  tympanum 
is  the  canal  I'oi-  the  tensor  tyinpani  muscle.  'I'liis  lies  just  aliove  the 
tymi)anic  orifice  of  the  Eustaeliian  tuiie.  The  pi'ocessus  cochleari- 
formis  which  forms  the  posterior  end  of  this  canal  projects  out  a  short 
distance  over  the  anterior  inariiin  of  the  oval  w  iinhiw.  (Fig.  94.)  The 
relation  of  the  facial  canal  to  the  innei'  wall  of  the  tympanum  is  of 
great  surgical  imjioitanee  as  the  laeial  nerve  in  its  course  through  the 
t\niii)anuin  is  eo\-ereil  !iy  .-m  i'\l  ieniel\-  thin  delieate  covering  of  bone 
wliich  can  readil\-  he  fractured  hy  the  use  df  a  nirette.  The  nerve  en- 
ters the  tymiiannm  in  front  of  and  just  above  the  oval  window.  Its 
course  is  more  or  less  horizontal  until  just  posterior  to  the  oval  win- 


118 


OPERATIVK    sriUiERY    OF    Tl  1  K    .VnSK,    Tl  1  IK  lAT,    AMI    V..\\\. 


(low  it  curves  (Idwnward  toward  tlic  styltmiasloid  opciiiiiii-.  (Fi.n's.  80, 
81,  90,  93,  94,  96.)  The  ]jroiuinence  formed  by  the  liorizoiital  seniicir- 
eidar  canal  in  the  floor  of  the  passage  from  tlie  antrum  into  the  tjnn- 
liaiimii  projects  out  beyond  the  facial  canal  and  in  this  way  serves 
often  U)  protect  the  nerve  from  injuiy  wlicii  operating  in  this  region. 

The  roof  of  the  tympanum  is  foniicd  by  a  i)late  of  bone  separating 
this  cavity  from  the  middle  fossa.  This  is  called  the  tegmen  and  is 
often  extremely  delicate.  (Figs.  77,  SO,  90,  94,  95,  98.)  In  the  new-born 
it  is  crossed  by  the  suture  between  the  sciuamos  and  petrous  bones 
through  which  blood  vessel  communications  extend  between  the  dura 
and  the  membrane  lining  the  tympanum.     Through  this  tegmen  sup- 


Fig.  96. 

Section  througli  the  mastoid  and  tympanic  cavity,  showing  the  relation 
of  tlie  horizontal  and  superior  canals  to  the  antrum. 


pui-ativc  disease  in  the  tympanum  frecpu^utly  penetrates  into  the  brain 
cavity. 

The  floor  of  the  tympanum  contains  a  numl)er  of  depressions 
called  tympanic  cells.  These  cells  are  occasionally  quite  extensive  in 
which  ease  it  becomes  difficult  if  not  quite  impossible  to  clean  them  out 
entirely  in  operating  on  the  tjTupanum.  (Fig.  97.)  The  floor  of  the 
tympanum  extends  somewhat  deeper  than  the  floor  of  the  external 
meatus.  This  depression  is  called  the  recessus  hypotympanicus.  The 
relation  of  the  bulb  of  the  jugailar  to  the  floor  of  the  tympanum  is  such 
that  infection  occasionally  extends  from  the  tympanum  directly  to  the 


TIIK    snidlCAI.    AXATd.MV    (iK    ■|lll'.    KAl!. 


ll!l 


bull).  'J'iio  luilli  is  l'rci|iiciilly  ('Xi)osc(l  to  injiiiy  wlicu  ciircltiiiir  tlii' 
floor  of  the  tynipamiiii.  \u  most  cases  \\u-  Imlh  is  separated  from  the 
tyiniiamiin  by  a  lliick  wall  .if  bone.  (Fi<i-.  ".m. )  In  otlier  oases  the  bulb 
I'onns  a  ]ii-(iniiiicncc  in  the  Ibmi-  oT  this  cavity.  It  is  then  covered  by 
an  extn'nu'ly  thin  slirll  nf  hour  readily  ln-dki'n  by  lln'  cni-ctto.  (Fijr. 
98.) 

In  tlio  anterior  wall  of  ihc  tynipannni  is  h)catcd  the  tynijianic  ori- 
fice of  the  Enstaehian  tube.  (Fig's.  S2  and  Oo.)  The  int<'rnal  carotid 
lies  directly  in  front  of  the  tynipannni  from  wlilcli  it  is  si'iiarated  l)y 
a  thin  plate  of  bone.  (Figs.  SO.  Si!.  90.  94.)  In  peirorming  the  radical 
mastoid  it  is  important  to  reniciubei-  that  the  carotid  lies  below,  that 
is  internal  to  tlie  Eustachian  tnbe.  in  (uder  to  avoid  injuring  this  ves- 
sel the  pressure  oT  the  curette  in  t  lie  uinni  h  ol'  t  he  1  ube  must  be  directed 
upward,  that   is  (Uitward.     The  mesial  wall  nf  the  1nbe  should  not   be 


Horizontal  section  througli  tlio  temporal  bone  seen  I'roin  liclow.     A  large 
tympanic  cell  developed  near  the  floor  of  the  tjnnpiuuim. 


curetted.  I'neiiiiiat ic  ci'lls  ai'e  rrei|Ueii1  ly  rdiiiid  npeninii-  iuin  the  Eu- 
stachian tube  near  the  tympanum.  These  are  the  tubal  cells  and  at 
times  they  are  quite  extensive.  (Fig.  95.)  On  account  oi'  tlu'  relation 
of  the  internal  carotid  it  is  often  not  feasilile  to  eradicate  these  tubal 
cells  when  iierfoi'ining  the  radical  mastoid  operation. 

in  the  posterior  wall  dl'  tlie  tynipaiiuui  is  located  liie  openiui^'  into 
the  antrum.  (Figs.  94  and  H.").)  This  opeiiimi  occupies  about  the  up- 
per third  of  the  posterior  wall.  The  canal  \'ny  the  facial  nerve  forms 
a  slight  |ir(iminenee  along  the  mesial  wall  of  this  opening.  (Figs.  90  and 
94.1  At  the  lower  margin  of  the  opening  tlie  facial  canal  enters  the 
l)osteri(ir  wall   of  the  tyuipainim.     Toward   tlii'  ihicir  nf  tile  tympanum 

this  canal  I'ecedes  more  ami  iiinre  \'\- llii'  posterior  wall  of  tlie  cavum 

tyni])ani.  (Figs.  SO  and  si .  i  .\  small  lioiiy  prominence  just  back  of  the 
oval  window  contains  an  opening  for  the  transmission  of  the  tendon  of 


120 


(iri:i;ATi\i';  srr.dicKV  di'"  'niK  xosi';.  'I'iiiioat,  atco  kai;. 


tlic  slapcdiiis  muscle.  'I'liis  ]ir(iiirni('ncc  is  railed  the  eiuiueiitia  jiyra- 
miilalis.  (Fig-.  9-1.)  The  depression  in  the  ])usterioi-  wall  nl'  the  tym- 
panum, called  the  sinus  tyni])iinicus,  lies  directly  nuder  tiie  eiuiiuMitia 
l^yramidalis. 

The  extei'ual  or  outei-  wall  of  the  tympanum  is  i'mined  chiefly  by 
the  niembrana  tympani.  At  the  floor  of  the  tyTXipannm  is  a  depression, 
the  recessus  hypotympanicns,  the  external  Avail  of  Avhieh  is  foraied  by 
tlie  floor  of  the  bony  meatus.  (Fig.  76.)  At  the  upper  part  of  the  tym- 
panum is  the  recessus  epitynipanieus,  the  outer  wall  of  which  is  formed 
by  the  bone  forming  the  roof  of  the  external  meatus.     (Fig.  76.)     In 


Fig.  9S. 
Section   tlnougli   tciiiiHual    l.niip,   .showing'   relation    of    llio   luillius   jugu- 
laris  to  caviim  tynxpani  and  lolations  of  tlie  coelili'a  and  facial  canal  to  the 
canim  tympani. 

removing  the  external  wall  of  the  so-called  attic,  there  is  danger  of 
injuring  the  facial  nerve  as  this  structure  in  its  course  through  tlie 
tympanum  lies  directly  internal  to  the  loAver  margin  of  the  external 
Avail  of  this  chamber. 

When  curetting  out  the  tympanic  cavity  great  care  must  be  taken 
on  account  of  the  danger  of  injuring  important  structures.  In  the 
floor  of  the  tympanum  is  the  recessus  hypotympanicns  and  the  tym- 
panic cells  whicli  frequently  require  cleaning  out  when  perfoiTaing 
the  radical  operation.  Here  the  danger  of  injuring  the  bulb  of  the 
jugular  must  be  kept  in  mind.  Along  the  posterior  wall  of  the  tym- 
panum are  several  depressions,  the  largest  of  which,  the  sinus  tym- 
panicus,  extends  often  under  the  canal  for  the  facial.    These  cells  are 


TIIK    SriICICAl.    AXATiiMV    ol'    TIIK    KAl!. 


121 


cxposi'i]  Hilly  liy  rciiKiviiii;-  tlic  \r,\\xi-  i>\'  Ikuu'  in  iVniil  hI'  tlir  I'acial  (•aiiiil 
ill  till'  lower  liair  of  the  iiustcridr  wall  nf  the  iiicatiis.  (  l''ii;-s.  SO  and  HI.) 
Ill  the  tiddi-  III'  thi'  l';ii>tacliiaii  tiiKf  iirar  its  tyiiipanic.  orifice  arc  the 
lulial  cells,  which  iiiusi  he  (ipciHMl  with  urcat  caution  on  account  of  the 
location  of  llic  iiiti'rnal  carotid  just  antciior  and  internal  to  the  tym- 
liannin  and  internal  to  tiie  Eustachian  tnln'.  The  roof  of  the  tyra- 
jianum,  the  tognicu  tjnupani,  scjiarales  this  cavity  troiu  the  middle 
I'ossa.  It  is  a  fra,s>ilc  shelf  of  hone  easily  ])crforated  by  a  curette.  In 
curcttiusi-  the  inner  wall  of  the  tyinpaunin  the  i-ejiion  just  below  and  in 
front  of  the  ]n-oniincuco  for  the  horizontal  canal  slionhl  be  avoided  be- 
cause the  facial  canal  crosses  the  lyMi|iannni  liere  and  in  this  region  is 
the  oval  window  with  the  stajics.  A  dislocation  of  the  latter  may  lead 
to  an  infection  of  the  lahyrinth. 

The  relations  of  the  lateral  sinus  are  important  to  keep  in  mind 
not  only  when  operating  on  the  sinus  itself  but  whenever  an  opening 
into  the  mastoid  is  made.  The  variations  in  the  location  of  the  sigmoid 
curve  of  this  sinus  are  such  (hat  unless  the\-  are  understood  there  is 
often  gi'eat  danger  of  opening  the  sinus  when  performing  the  simple 
mastoid  operation.  The  si,<inuoid  usually  lies  far  enough  jiosterior  to 
the  external  meatus  to  iierinii  ol'  a  \'yfv  openini;  into  the  antrniii.  (Fig. 
82.)  It  frequently  projects  forward,  however,  so  close  to  the  ])osterior 
wall  of  the  external  meatus  that  a  fi'ce  opening  from  the  surface  of 
the  mastoid  into  the  antrum  is  obstructed,  it  nsnally  lies  at  a  consid- 
erable distance  from  the  surface  of  the  mastoid  but  in  those  eases  iu 
which  the  sinus  is  pushed  forward  it  apiiroaehes  closer  and  closer  to 
th(i  surface  of  the  mastoid.  It  can  be  st'cii  in  some  cases  after  the 
)ieriosl(Miiii  lias  been  reiiiovi'ij,  as  a  bluish  discoloration  from  the  sur- 
face of  tile  mastoid.  In  all  ca>es  the  cortex  of  the  mastoid  should  be 
reiiio\-ed   with  caution   until   the   location  of  the  sinus  has  l)eeu  <leter- 

iiiiiied.     In  rare  cases  there  is  a  congenital  alisem I'  the  lateral  sinus 

on  one  side.  The  author  has  one  siieli  preparation  in  his  collection. 
Near  the  uiiper  ])()sterioi-  margin  of  the  mastoid  process  the  sinus 
take-  a  horix.oiilal  direction  backward.  .\t  aliont  tlie  level  of  the  Hoor 
of  the  t.viiipanuni  the  sinus  turns  inward  and  somewhat  forward  in  a 
liorizontal  direction   towards  the   Inilli. 

The  !.o>itioii  of  tlie  Inilh  of  the  Jugular  and  it>  relation  to  the  sur- 
roniidiiig  >trnctures  must  he  iiiidei>tood  hy  the  surgeon  who  under- 
takes to  operate  on  the  mastoid.  In  cases  of  infection  il  becomes  neces- 
sary to  exiwse  the  Inilh  and  lo  lay  it  frecl>  open.  Tlir  relation  of  the 
hiilb  to  the  cavuni  1\  inpani  has  already  liccii  div-rrilicd.  When  the  bulb 
occupies  that  relation  to  the  lloor  of  the  tyiiiiiannni  which  is  .shown  in 


122 


orKI'vATIVE    sriiCKKV    OF   TITE    XOSE,    TIIRDAT,    AM)    EAK. 


Fiii".  !)8  or  ill  Fig'.  90  an  oxposure  of  tlic  Imlli  Uy  (i|HT;itiH,n'  llirousi'li  the 
tyinpamnn  is  feasible. 

Tlie  locatioTi  of  the  l)ulli  varies,  however,  even  more  than  does  that 
ol'  the  lateral  sinus.  In  most  cases  the  Inilb  makes  but  a  shallow  inden- 
tation in  tile  lower  surface  of  the  temporal  bone,  so  that  a  curette 
passed  forward  along  the  lateral  sinus  will  remove  clots  located  in  it. 
In  these  cases  it  is  separated  from  th(>  floor  of  tlie  tymjiannm  by  a 
tliiek  layer  of  bone.  In  other  eases  the  dome  of  the  jugular  bulb  is 
pushed  upward  higher  and  higher  along  the  posterior  wall  of  the 
petrous  bone.  In  these  cases  the  appearance  is  not  nnlike  an  erosion 
produced  by  an  eddy  in  a  stream.  The  extent  to  which  the  bulb  is 
pnshed  upward  in  these  cases  is  often  surprising.  Occasionally  the 
bulb  extends  to  the  highest  margin  of  the  petrous  bone.  In  Fig.  100  is 
shown  a  case  in  which  the  bulb  extends  through  the  superior  margin  of 


Hiiiiziiiitiil  section  tliviuii.Ii  the  teiii|i(iial  bone  seen  t'l 
velntiiins  of  tlie  biillius  jiisularis  to  tlie  Interal  sinus. 


above,  sliowinf; 


the  petrous  bone  and  in  its  course  obliterates  part  of  the  postei'ior  wall 
of  the  internal  meatus  as  well  as  the  bony  covering  of  the  aqufeductus 
vestibuli. 

The  surest  route  for  the  exposure  of  the  jugular  bulb  is  to  fol- 
low along  the  course  of  the  lateral  sinus  until  the  bulb  is  reached.  By 
chiseling  along  in  front  of  the  sinus  a  layer  of  bone  can  be  removed 
Ijosterior  to  the  facial  canal  which  will  usually  permit  of  a  more  or  less 
free  exposure  of  the  bulb,  depiending,  of  course,  on  whether  the  bulb 
is  shallow  or  deep.  The  thickness  of  the  bone  that  can  be  removed  in 
this  way  along  the  anterior  wall  of  the  sinus  without  an  injury  to  the 
facial  nerve  is  often  as  much  as  0.5  cm.  (Fig.  99.)  Care  must  be  taken 
in  making  this  opening  into  the  bulb  not  to  extend  the  chiseling  too  far 
up  along  the  posterior  surface  of  the  petrous  bone  for  here  there  is 
danger  of  opening  into  the  posterior  semicircular  canal. 


Tlir.    SriKllCAI.    ANATdMV    HI'     TIIK    KAK. 


1  2:5 


Til  oniiiKM'tii'ii  with  the  sinuicnl  iclnlimi  of  tlic  lateral  .sinus  it 
shoiiM  lie  m.-ulioiicl  tiinl  this  >linr|iirc  s.Tvrs  as  llic  best  guide  for 
the  oin'iiiiiii'  i>r  a  rt'rclicllar  alis<'css.  'riicsc  ahscossrs  lie  usually  snuio- 
whero  alouii'  the  iioslcrior  surface  of  llic  ])efr()us  lioiic  in  fnml  dl'  the 
lateral  sinus.  'I'd  atteni|il  to  ili-ain  >ucli  an  alisccss  liy  an  ii|iiMiinu-  liadc 
of  the  sinus  is  niore  (liflieull  liecaux'  n\'  the  ^icat  distance  from  the  sur- 
face. The  hest  I. Mile  liy  wliirh  lo  reach  tliese  ahscosses  is  by  uiakin.a,- 
an  oiieiiini;-  in  lidut  df  the  h-iteial  >inus.  If  the  anterior  wall  of  the 
lateral  sinus  is  fiiHoweil  and  llie  chiseiini;  is  not  carried  too  far  for- 
ward it  is  |)dssilih'  td  e\|id>e  tile  ceicliel I uin  witliout  au  iiijuvy  of  the 
])()<tei-i()r  seniicii-cuL-ir  canal  |ird\ided  tliat  the  ahscess  is  not  sec(Hidary 
to  a  lai)yi'iuth  supjiuration. 


Fig.  100. 

View  of  tlie  |)ost<>rior  a.siicct  of  tlio  tonipoval  Iioiic,  showing  Inillms  jug- 
ularis  extending  to  tlie  upjier  ni;ugiu  of  tlic  petrous  liono.  (Anatomical 
variiition.) 


^riie  snri;ica]  anatdiny  df  the  lahyiintli  i-.  lic-t  exiiiained  in  Cdu- 
neetidii  with  the  d|iei-ali(in  du  the  iahvrinth.  in  tliis  cdinieetidU  aflen- 
tion  may  lie  cuMed  id  tlie  ivlntidn-  df  the  laliyrinth  td  the  middle 
ear  chamhers.  In  the  c-ixniii  t\nipani  the  ea|i>nle  dl'  the  |;ili>rinth  is 
I'reely  exijosed.  The  iirdmnntdiy  dii  the  imuT  \\all  i>  formed  hy  the 
large  turn  madi'  hy  tlie  iie,<;inninf'-  of  the  hasal  coil.  By  chiseling  from 
the  lower  edL;e  df  the  fenestra  vestibuli  a  free  opening  into  the  vesti- 
bule is  made  and  in  remox  ini:  \\\f  pi'diiidntdix  \']-i-t'  drainai^c  df  thi'  <'dcli 
lea  is  acc(niiiili>hed.  in  i-emd\in,i;  the  pidiiidntdry  the  i-elatimi  of  the 
bnlli  df  the  .jugular  >lid\vn  in  fig.  !•"<  -honld  he  kept  in  mind.  In 
Jn.-t    >nch   a   ca>e  the  author   ha-   dpened   the    hnlli   while    iemd\in,i;'   the 


124  (IPKRATIVK    sri'.CKI'.V    Ol'    Tl  1  K    XOSK.    T 1 1 IIOAT,    AM)    KAI;. 

proinoiitdiy.  Tlic  apex  of  tlic  coclili'.-i  can  lie  ('X|ii)S('(|  hy  cliiscrniL:-  I'or- 
^\;u•^l  IVinn  the  aiiti'rior  iiiai',i;in  ol'  lln'  oxal  window.  TIh'  apex  of  llic 
('(icliica  lii's  inti'i'nal  \n  IIm-  t\iii|)ani('  oi'ilicc  ol'  llic  I']iis1acliian  tulic 
Its  relation  to  the  internal  earoti.l  lyin,i;'  just  ])os1eri()r  or  extei'nal  to 
this  stnictuve  makes  it  iieeessavy  to  exercise  ,ureaf  cai'e  when  workiiii;- 
ill  this  region. 

Two  of"  the  seiuicivciilav  canals  come  into  more  or  less  close  i-ela- 
tion  to  the  middle  ear  cavities,  the  hoii/oiital  and  the  superior.  The 
capsule  of  the  horizontal  canal  forms  a  white  glistening  prominence 
readily  seen  in  opening  the  antrum.  It  lies  in  the  floor  of  the  rocessus 
epitympanicus  at  the  point  whei'e  this  o))ens  into  the  antrum.  The  re- 
lation of  the  superior  canal  to  the  middle  ear  is  not  nearly  so  intimate. 
It  lies  just  above  the  anterior  end  of  the  exposed  ])art  of  the  horizontal 
canal.  In  this  way  its  anterior  cms  is  readily  exposed  by  chiseling 
above  the  ])rominence  of  the  horizontal  canal  and  directly  over  the  oval 
window.  In  opening  this  canal  the  position  of  the  facial  nerve  along 
the  upper  margin  of  the  oval  window  must  not  be  forgotten.  The  pos- 
terior semicircular  canal  does  not  come  into  close  relation  to  the  mid- 
dle ear.  It  can  be  reached  by  removing  the  triangular  piece  of  bone 
between  the  superior  and  the  horizontal  canals. 


(•|i.\rTi;i;  i\\ 

KXTERNAL  OPHRATIONS  ON  THI<  LARYNX.  I'llARVNX.  HTI;R 
KSOPIIAIil'S,  AND  TRACIII'A.^ 

Jiv  CKdiKJK  AV.   Cnii.i;.   M.   J). 

Special  Difficulties  and  Dangers. 

The  toclinio  of  oxloni;il  opt'ralioii.s  upon  Iho  i\\>\Kn-  air  passages  and 
llio  osoiiliaiius  Avoukl  hv  sinii)lo  t'ii()iii;li  wore  it  not  for  certain  special 
dillicnlties  and  dan.c'ors  jieculiar  to  these  oi)erations.  It  is  avcII  tlierc- 
fore  to  first  consider  these,  that  the  full  signilicance  of  the  various  steps 
of  the  operations  to  be  described  later  may  be  more  fully  appreciated. 

Pneumonia. — PneiiTiinnin  t'ollcnving  nporntion  on  the  upper  air 
passages  is  due  in  iiinst  iii>i;iiirrs  In  mn'  nf  Iwn  causes:  (a)  tlic 
inhalation  of  blood  or  niucus,  and  (It)  the  inhalation  of  infected  wound 
discharges.  These  injurious  inhalations  occur  usually  in  the  course  of 
the  operation,  although  occasionally  the  postojierative  oozing  is  in- 
Jialod.  These  dangers  nmy  be  pn-evented  in  i)art  by  scruiiulously  main- 
taining a  dry  field  during  the  entire  (-(mrse  ii\'  the  dissection.  This  is  ac- 
complished by  picking  up  e\-eiv  xcssel  large  enough  to  be  considered  at 

all,  either  before  dividing  it  or  inn liately  after  it  had  been  divided. 

In  this  manner  tlie  field  will  lie  kept  sn  clear  of  lilood  tlnit  all  an- 
atomic structures  may  lie  easily  seen  and  ideutilied.  During  the 
later  stages  of  the  dissection  the  vessels  which  have  been  ])icked  up 
may  be  ligated  with  either  light  catgut  or  light  silk.  AVhile  this  man- 
ner of  dissection  may  at  first  seem  to  lie  tedious,  it  will  in  the  end 
prove  the  quickest  method,  and  is  the  method  of  choice  in  dissections 
foi'  the  exposure  ni'  ilie  laryux,  pliaiyiix,  trachea,  or  esophagus.  When 
the  field  of  oiicration  has  lieen  reaeiied,  however,  the  prevention  of 
blood  inhalation  becomes  (piite  a  dilTeiint  jiroblem,  because  the  blood 
supply  of  the  mucous  nu'inhi-ane  is  maintained  principally  by  terminal 
arterioles  Avhich  cauunl  he  elTectively  controlled  by  ligaliiui.  At  this 
I)oint  in  the  ojieiatiou  one  nl'  two  enui'ses  may  be  adopted.  The 
patient  in;iy  lie  |ilaeed  in  a  lie.-id  dnw n,  inclined  jiosture  at  such  an 
angle  that  the  lilood  will  i;i-a\itate  ;i\\ay  fidui  tin-  lung:  (ir  liy  the 
hypodermic  use   of  novocain    ami    adrenalin    the   trachea,    the   larynx, 

*Operations  within  the  larynx  through  I'Ktcrnal  it^cisions  will  he  considered  in  the  chapter  on 
cndolaryngeal  operations. 


12(>  (ii'KiJA'i'ivi';  sri;(;Ki;v  nv  tiik  nmisk.  tiu'.oat,  and  f.ai;. 

and  llic  iiliavyiiN  may  l)c  iMitcrcd  witliniit  i-csiiltaiit  ediiuhiiii;'  or  nia- 
tci-ial  oDzinu'.  ir  I  111'  inucdiis  niciiiliram'  has  Ix'cii  locally  anesthetized 
the  bleeding  may  usually  lie  controlled  by  the  local  applieation  of 
pledgets  of  cotton  saturated  with  adrenalin  pressed  firmly  against  the 
bleeding  ])oints  by  hemostatic  forceps.  The  further  control  of  hemor- 
rhage dejtends  nj)on  the  circumstances  of  the  individmil  operation.  If 
conditions  peniiif,  a  rul)l)er  tube  which  snugly  fills  the  trachea  or  even 
distends  it  will  entirely  control  the  dangerous  factor  of  blood  inha- 
lation. 

There  are  both  advantages  and  disadvantages  to  the  control  of 
hemorrhage  by  ])osture,  for  the  amount  of  hemorrhage,  especially  of 
venous  hemorrhage,  is  increased  by  gravity.  Then  too,  the  head-down 
position  is  less  favorable  for  the  operator.  The  direct  control  method 
has  the  advantage  of  light,  accessible  position  and  the  minimum  bleed- 
ing. The  author  has  rarely  found  it  necessary  to  resort  to  the  head- 
down  posture,  although  it  has  sometimes  been  temporarily  used  during 
some  phase  of  an  operation.  Occasionally,  of  course,  a  great  emer- 
gency may  exist  in  whicli  the  head-down  posture  is  urgently  demanded. 

Local  Infection. — Tlie  next  great  daiigcM-  associated  Mith  opera- 
tions on  tlie  \i|i}ier  i-es])iratoi-y  tract  is  lliat  ot  local  infection,  t'oi-  it 
may  happen  that  after  the  air  ])assages  have  been  opened  a  serious 
local  infection  Avill  spread  over  tlie  contiguous  territory  and  along  the 
deep  planes  of  the  neck.  The  occurrence  of  some  infection  must  be 
taken  for  granted,  but  it  is  for  us  to  consider  by  what  means  the 
amount  and  the  virulence  of  the  infection  may  be  diminished  and  how 
it  can  l)e  localized.  In  the  first  place,  the  danger  may  be  minimized 
in  advance  by  canvassing  all  of  the  contiguous  territories  and  mak- 
ing sure  that  there  are  not  present  any  active  foci  of  infection,  such 
as  decayed  teeth,  pyorrhea,  alveolar  abscesses,  discharging  sinuses, 
peritonsillar  abscess,  pharyngitis,  oi'  imrulent  rhinitis.  At  the  time 
of  the  operation  itself  we  may  control  tiie  local  severity  of  the  infec- 
tion by  using  only  sharp  dissections  and  by  minimizing  to  the  utmost 
the  trauma  of  surrounding  tissues;  by  leaving  no  oozing  of  blood;  by 
making  careful  decisions  as  to  the  immediate  closure  of  the  soft  parts 
overlying  the  wound;  and  by  using  iodoform  packing  if  there  must 
be  any  wound  in  the  soft  parts  of  the  throat  and  neck.  When  infection 
has  been  inaugurated  there  are  no  better  theraiseutic  measures  than 
the  hot  pack  and  the  inhalation  of  medicated  or  plain  steam. 

Mediastinal  Abscess. — After  pneumonia,  mediastinitis  and 
me<liastinal  abscess  have  been  the  most  fatal  after  results  of  the 
operations  we  are  considering.  The  onset  of  infection  is  usually  a 
week  or  ten  days  after  the  operation,  and  is  characterized  by  a  steeple- 


LAr.VXX,     I'llAKVNX.    ri'I'KI!    ESOIM I  AC  IS.    ANH    TI'.ACI  I  KA.  127 

cliase  tomiKTiituri'.  not  liiuli,  and  always  rcniiltiim-  in  (he  nntrninu'. 
Tliere  is  usually  hut  littlo  pain,  and  tlu'  cdursr  nl'  llif  diM-asc  is  toward 
slow,  but  certain  death.  Tn  many  rcsiircts  il  ri'scinhli's  the  rcti'o- 
])(>riton('al  ahsccsscs  which  also  conic  lali'.  aif  alimisl  painless.  proi^M'css 

slowly.  >hn\\  a  >ti'r|)lcclia-i'.  Imt  lnw  Iciiipcral  iiri'  cui'xc.  anil  md  nsnally 
in  death.  The  explanation  of  the  cliaractciivt  ic,  painless,  tt'dimis  and 
fatal  course  of  mediastinal  abscess  is  prulinlilx  rnund  in  the  fact  that 
this  v(\t;ion  of  the  body  has  always  liccn  innicctrd  rrtmi  wounds  by  the 
lioii\-  elii'>t  w;dl.  iM'ini;'  cldx^d  In  wdiiiids  tlirons^li  the  \a>t  pcfiods  of 
man's  cv-olntion.  it  lias  hccn  rloscd  likewise  to  infection.  The  tissue 
ot'  this  proteete<l  region,  thei-efdre,  has  not  heeii  eiidnwcd  with  the 
elements  rciiuired  to  ellicientl)'  meet  .-md  ii\ creniiie  infection  as  have 
been,  for  example,  the  peritonenin  and  the  exlei'iial  par1>  of  th(>  body, 
ill  \-iew  of  this  fact,  we  ninst  unai'd  this  helpless  teri-iliir_\-  witii  speeial 
care. 

As  we  ha\'e  shown  that  incoperatix-e  nieasiii-es  may  in  lari;-e  dei;ree 
pre\ent  tlie  extensive  cdiirse  of  local  infection,  so  tlie  danii'er  of 
iiiedi;i-l  iiiitis  may  he  unarded  a,i;aiiisl  li\  pieoperati\e  pnitecticni.  II' 
in  the  conrst'  of  a  larsii-ei'toiiiy,  for  instance,  tlie  di\-ided  trachea  is 
stitche(l  to  the  skin,  there  is  i^ri^at    danger  that    snbsecinent  con.ii'hing 

will    cause    il     to    liecolne    detached.        its    llloolilll^s    I  la  \  i  111;'    been    lost,    it 

will  l)e  thrust  hack  and  forth,  in  and  out  of  the  thoracic  box,  like 
the  piston  of  an  eniiine.  Mediastinal  infection  will  he  the  almost 
imn-itable  result.  If,  on  the  other  hand,  the  free  end  of  thi>  trachea 
is  not  tixi'd  hy  sutures,  hut  is  held  hy  L;nnzc  packini;  ahinit  it,  then 
the  trachea  will  retract  within  the  thoracic  cai;e  like  the  head  of  a 
turtle,  and  auiain  infection  inn~t  result.  It  is  oh\-ious,  then,  that  the 
trachea  should  he  so  fixed  hy  preliminary  operation  that  there  may 
he    ]iroduced    all    iii\incihlc    harrier    of   manulations    extending   across 

the    hase   of    the    1 k    all  I    the   eiitiance    to    the    tliorncic    eai;-e.      Thei-e 

are  two  methods  hy  which  tins  may  he  ihnie:  The  ordinary  sini|ilc 
1  racheotoniy  will  lix  the  trachea  and  will  stimulate  lli<'  formation  of 
elhcieiit  .yrannlatioii  li-siie;  or  ex|iosin,u-  the  trachea  and  the  lower 
laiNiix  and  packiiii;  the  lateral  planes  of  the  neck  with  iodoform  y-auze 
will  result  in  the  |irodiiction  of  ^rannlat  imis  and  in  lixiiii;'  the  tracliea 
so  firmly  that  con^liiim  cnmiot  lueak  its  mooiin.us.  \\nr\i  of  these 
methods  of  itself  alone  Ims  certain  advantai^es  and  disadvantages.  The 
simide  tracheotomy  is  not  so  certain  a  safe.unard  asninst  infection  of  the 
niedia-tinum  as  is  the  latter  method,  and  it  docs  not  result  in  so  linn  a 
fixation  of  the  tiachea  in  the  deeper  jiarl  of  the  neck:  hut  il  has  the 
advantage  of  estahlishinu'  a  strong  defense  mechanism  in  the  mucous 
membrane  of  the   trachea    itself.     <  »n    the   other   hand,   the   jiackiiig  of 


12S  i>pki;ativk  si-kckiiv  or  tiik  xusk,  tiiuhat.  anh  k.ai;. 

Uie  ck'C'|(  |iliiii('s  with  iodoronii,  wliilf  otherwise  nil  ideal  protectiou, 
does  not  sup]il\-  the  ])rotective  defenses  in  tlie  imicous  membrane  of 
the  trachea.  An  ideal  defense,  then,  is  fonnd  in  a  comhination  of  the 
two  operations,  that  is,  in  opening  and  packin,<i-  the  (h'<'))  jilanes  of  the 
base  of  the  neck,  and  at  the  same  seance  niakin,"-  a  low  traclieotomy. 
By  this  means  tlie  mediastinnm  is  put  under  strong  guard,  and  at  the 
same  time  the  later  technic  of  the  operation  is  measurably  reduced. 

Vagitis. — Though  a  less  frequent  risk  than  those  we  havi'  deseril)ed, 
vagitis  represents  a  formidable  and  special  danger.  In  the  course 
of  the  convalescence  following  laryngectomy,  usually  after  the  fourth 
day,  a  group  of  new  sym])toms  is  occasionally  introduced;  the  pulse 
becomes  very  ra^oid  and  irregular  in  rate  and  rhythm — it  may  jump 
from  90  to  140  in  a  few  minutes;  the  heart's  action  becomes  tumultuous 
at  times;  the  patient  is  quiet  or  perhaps  a  little  apprehensive.  Death 
from  vagitis  has  been  reported,  though  in  the  author's  cases  the  symp- 
toms passed  after  a  rather  boisterous  course  of  a  few  days.  It  is 
probable  that  the  trunks  of  the  vagi  have  become  involved  in  the 
wound  infection  and  as  a  result  these  nerves  have  been  rendered  unfit 
to  properly  conduct  stimuli.  Hence  there  arises  the  striking  conflict 
between  the  vagus  and  the  accelerator  control,  the  picture  being  very 
similar  to  the  immediate  effect  of  crushing  or  dividing  both  vagi 
simultaneoiTsly.  As  a  protection  against  this,  one  might  utilize  the 
well-known  physiologic  fact  that  the  division  of  one  vagus  causes  no 
notable  change  in  the  heart's  action.  In  the  course  of  extensive  dis- 
sections for  the  wide  excision  of  cancer  of  the  neck,  the  author  has  eight 
times  excised  a  portion  of  the  trunk  of  one  vagus.  Close  observation 
of  the  pulse  and  respiration  detected  no  change  nor  was  any  later 
alteration  observed.  Following  this  indication,  then,  at  the  preliminary 
operation  one  should  carry  the  dissection  on  one  side  of  the  larynx  all 
the  way  to  the  upper  margin  of  the  field  of  final  operation,  and  should 
pack  this  territory  wdth  iodoform  gauze  just  as  the  deep  planes  of  the 
neck  are  packed.  By  this  procedure  one  vagus  must  take  the  brunt 
of  exi^osure  and  adjustment  liefore  the  larynx  is  removed.  By  the 
time  the  laryngectomy  is  done  this  vagus  would  be  readjusted  and 
ready  to  resume  its  function  in  case  it  was  affected  at  all,  and  so  the 
heavy  onslaught  of  the  vagi  ui)oii  the  heart  would  not  be  made  by 
both  vagi  simultaneoush'.  In  the  case  in  wliicli  the  author  tried  this 
plan  it  seemed  to  be  completely  effective.  "When  vagitis  has  become 
established  there  is  little  that  can  be  done  to  aUeviate  it,  althougli 
hot  ap])lications  are  apparently  of  some  sei'\'ice. 

Reflex   Inhibition   of  the   Heart   and  Respiration   Through  Me- 
chanical Stimulation  of  the  Superior  Laryngeal  Nerves.- This   is  a 


LARYNX,  ru.vmNN.   I  iTi-.i:   ::si in lAi; I  s,  wn  tkaciiea.  llll> 

Tiiiiior   pIu'iimiiiMion    ])rculiar   Id   Hie   >iir.t;ci->    ol'  tliis   I'l'iiion.   Kut    il    is 

li'pnili'il     In     li;i\i>     IC.-ullcl     ill     ,-('\rl;il     (lr;itll>     ;ill(l     lin-     (■.•IUm'iI      niUc-|| 

aiixit'ty  aiiil  iMnilili'  lo  ihovr  wlm  liavc  iic\('|-  knnwn  ol'  its  (■xislnicc 
and  wild  lia\c  not  known  how  |o  iiitiT|ii  rl  ami  oli\  iatc  il.  In  a 
laryiigccldiiiy  the  tciininals  of  I  lie  superior  larynj^cai  iici'vi's  in  llic 
larynx  and  on  the  surracc  ol'  tiic  liiiia  uloltidis  arc  of  iicct'ssily  dis- 
liiiitcd.  and  till'  trunks  ol'  liicsc  nerves  are  divided  in  the  cdurse  oT 
o])eration.  The  I'unclion  of  the  larNii'^cal  ihmxcs  is  the  |iroteetinn  ol" 
the  pulmonary  tract  rroni  tiic  entrance  of  I'liriMun  liodies.  Tlie  sliviil- 
ost  toucli  df  tlieii'  cndiiiL;>.  therefore,  causes  a  cou^li  I'cllex,  and  a 
stroufi'  contact  will  cause  an  iiihihition  of  resj)iralioii  and  of  tlio  licart. 
Tlie  nerve  su])])ly  ol'  the  tiacliea  has  no  such  I'unclion.  Init  the  area  of 
distribution  of  the  inliibitory  nerve  ending-s  extends  over  a  jiart  of  tlie 
pharynx  and  a  part  of  the  posterior  nares  even.  Fortunately,  wc  have 
an  absolute  protection  against  this  dramatic  and  sometimes  dangerous 
phenomenon,  in  the  hypodermic  adininisf ration  of  lldd  gi-ain  ati'opin 
(adult  do.se)  Ixd'ore  the  djieratidii.  In  additidii  a  >pia\-.  a  Ideal  appli- 
cation, or  the  local  hypodciinic  in.jectidii  of  novocain  a\  ill  confi-nl  abso- 
lutely the  inhibitory  reflexes. 

Selection  and  Care  of  Tracheal  Cannula. — The  last  special  dilli- 
culty  wliich  we  shall  consider  relates  to  the  after-care  of  tlie  patient, 
and  refers  to  the  selection  and  care  of  the  tracheal  cannula.  After 
trying  many  kinds  of  cannula',  the  aiithdi-  has  fduiid  that  the  counium 
male  or  female  curved  cannula,  or  plain  rublxu'  lulling  even,  will 
answer  all  puiposes.  The  greatest  care  should  l)e  exorcised  in  adjust- 
ing the  metal  tubes  so  as  to  i)reveiit  pressure  necrosis.  Rubber  tubing 
is  preferred  by  some  patients,  'ml  the  metal  tubes  usually  are  best. 
A  rubber  tube  drawn  over  a  metal  tube  is  perhaps  the  easiest  to  wear, 
but  the  author  has  found  that  patients  become  careless  by  their 
familiai'ity  with  danger  and  will  weai-  loose-fitting  tubes.  This  ]ioint 
was  strongly  impressed  on  the  author  by  the  difficulty  once  encoun- 
tered in  extracting  a  rnbiier  liiKe  that  had  slipped  off  the  metal  tube 
and  had  been  carried  deep  into  the  trachea.  After  a  stormy  session 
in  which  the  patient  almost  suffocated,  the  tube  was  caught  by  groping 
deep  within  the  trachea  with  a  curx'ed  henioslal  forceps  and  it  was 
extracted  while  the  jiatient  was  unconscious  from  aspli\\ia.  In  time 
all  laryngectomy  cases  get  along  without  lulies.  In  fact,  in  recent 
cases  the  author  has  been  able  to  disp<'nse  altogether  with  tracheal 
tubes,  both  at  the  time  of  the  operation  and  ever  afterward,  and  the 
author'-  )iatients  lia\e  all  pi-eferred  to  get  along  without  phonating 
apparatus. 


130  OPKIIATIVK    SIKi.KIM'    Ol'    TIIK    XdSK.    TIIIIUAT.    AXU    KAI;. 

Operations  on  the  Trachea. 

Tracheotomy. —  A  tiaclieotoiny  may  lie  lii^h  or  low,  an  emergency 
or  a  planned  ojjeration.  There  is  bul  little  difference  between  the 
technic  of  the  high  and  the  low  traciieotomy,  bnt  there  is  a  vast  differ- 
ence between  ])lanne(l  and  emergency  operations.  The  latter  will 
therct'dn'  be  described  se))ai'ately. 

Emergency  Tracheotomy. — Foreign  bodies  in  the  larynx  or 
trachea,  the  pressure  of  tnmors,  the  closure  of  the  trachea,  by  the  swell- 
ing of  previous  strictures,  the  pressure  of  an  abscess,  the  encroachment 
of  malignant  tumors  of  the  thyroid  or  other  tissues,  the  closure  of  the 
larynx  by  intralarjaigeal  tumors,  at  first  gradual  but  finally  sudden, 
and  many  other  causes  of  obstruction  may  demand  an  emergency 
tracheotomy.  Then,  too,  the  trachea  may  collapse  during  the  removal 
of  a  large  obstmcting  goitre — especially  if  the  operation  is  being  per- 
formed under  ether  anesthesia.  Whatever  the  cause,  this  emergency 
presents  one  of  the  most  dramatic  of  surgical  crises.  Under  the  iirgent 
necessity,  it  is  Tisuall}'  a  laryngotomy  and  not  a  tracheotomy  that  is 
performed.  But  in  the  presence  of  an  emergency  when  a  life  is  flicker- 
ing fine  distinctions  are  lost. 

In  emergencies  which  occur  in  the  course  of  operations  upon 
l)atients  Avho  are  laboring  against  respiratoiy  obstruction  there  are 
several  very  important  points  to  be  considered  in  the  effort  to  prevent 
respiratory  collapse.  First,  the  patient  must  be  kept  free  from  ex- 
citement,— by  morjihin  and  ati'opin  if  jiersdnal  influence  be  insuffi- 
cient. Under  excitement  respiration  is  accelerated.  The  resultant  in- 
crease in  the  exchange  of  air  at  once  accentuates  the  diminished  space 
at  the  constriction  and  makes  the  ]iatient  feel  acute  symptoms  of  suf- 
focation, whereas  (piiet  l)reatlung  can  be  accomplished  easily  through 
a  smaller  aperture.  Second,  a  little  mucus  may  precipitate  respira- 
tory ol)structioii.  ilajipily,  the  secretion  of  mucus  may  l)e  wliolly 
controlled  by  the  use  of  atropin.  Third,  a  general  anesthetic  is  abso- 
hately  contraindicated  Avhen  a  patient  is  exerting  more  than  the  normal 
muscular  action  in  effecting  an  exchange  of  air,  especially  w  hen  lie  is 
using  the  extraordinaiy  muscles  of  respiration.  The  author  has  seen 
instances  of  the  fatal  error  of  giving  a  general  anesthetic  to  such  a 
patient.  Inhalation  anesthesia  paralyzes  the  extraordinary  muscles 
of  resiDiration.  Tliese  muscles  are  used  only  when  enough  oxygen  to 
sustain  life  cannot  be  secured  by  the  action  of  the  ordinary  muscles  of 
respii'ation.  Under  these  circumstances  therefore  the  extraordinary 
muscles  become  vital. 

Therefore,  in  cases  of  respiratory  obstruction  in  which  the  extraor- 


i.AKVNN,     rilAinXX,     riM'Ki:    KSOIMIACrs.     AMI     TKACIIKA.  lol 

iliiiniy  iiiiiM-Irs  (if  respiration  nrc  uscil,  tlir  ii|ii'i-;itiiiii  inu^l  lie  jicr- 
rnriiicil  uiuliT  lcic;il  aiu'stlii'siii — iiiul  it'  W\  chaiici'  iIh'it  is  no  Incal 
aiu'stliotic  availalili'  it  must  lie  ddin'  witlumt  aiu'stiu'sia  <it' any  iviiid. 

The  ideal  state  t'or  npeial  imi  in  tlie  presence  of  )iartial  ol)sti-uction 
is  tile  iieneval  i|nieseenee  inndnci'il  li\  ninipiiin,  local  anostliosia  being 
secured  by  tlii'  use  ot'  noMiraiii.  When  an  emergency  traclieofomy  is 
to  be  performed,  it  is  iiest  to  put  tlie  patient  i|uicl<ly  in  tiie  'i'renilolen- 
l>eri>:  posture  so  that  the  hleediuL;.  whicli  nndei-  the  Inllnence  of 
asphyxia  is  sure  to  he  increased,  may  not  hi'  iidiahMJ  and  cause  a  septic 
lironcliitis  m'  pneumonia.  lu  enier^encii's  tlie  pnihahility  of  blood 
inhalation  is  so  i^reat  that  the  patient  >li(udd  at  once  he  plac<M|  in  the 
Trendeleid>i'r,';-  |)o-ition.  The  trachea  should  not  he  opened  by  a 
plunging  incision,  a  procedure  which  has  hi-(Uinlit  many  a  promising 
attempt  to  grief.  An  orderly  hut  aci'cleraled  dissection  wheri'by  the 
operator  may  ilistinctly  see  the  tracheal  riui;s  yields  the  (piickest 
red  i  cf  e\en  in  t  he  hands  of  master  surgeons  indeed  it  is  by  pei-forniing 
controlli'd  operations  that  one  heconies  a  master  surgeon.  As  soon 
as  the  trachea  has  heen  perforateil  nothim;'  hut  had  lechnic  can  cause 
the  jiatient  to  sulfocate.  if  the  soft  paits  are  sufliciently  retracted 
hy  instruments  or  fingers  (U-  hoth  so  thai  the  hlood  is  kept  out,  the 
patient  M-ill  do  all  the  bettei-.  A>  for  the  tracheotomy  tuhc  any  ph-er 
of  rubber  tubing  will  answer,  in  the  absence  of  rubber  tubing  or 
tubing  of  any  soit  tin'  tracheal  i-ings  may  be  stitched  to  the  skin  on 
each  side.  After  an  emerL;-eiic>'  opening  of  the  ti-ach(\a  ^vhicll  has  been 
pci'foi-nied  imder  the  partial  ain'stliesia  of  asphyxia,  the  patii.'Ut  will 
rapidly  revi\"e  uiuler  a  noimal  supply  of  oxygen  though  his  suffei'ing 
will  be  gi-eat.  Morphia  should  therefore  be  gi\-en  as  ipiickly  as  possi- 
ble, lu  the  nmnagement  of  the  excited  patient  upon  whom  an  einer- 
.i;'ency  tracheotomy  is  pierfornied  it  i>  important  to  take  extraordinary 
care  to  ]ii-e\ciit  fmiliei-  I'xciiemeiit  or  further  |iain.  Such  a  ]>atient 
needs  rt'st  and  ipiiet  to  regain  normal  composure. 

Planned  Tracheotomy. — The  selection  of  the  )iosilion  for  a  trache- 
otomy depend-  eutiridy  upon  the  condition  foi-  the  ndicf  of  which  the 
ojieratiou  is  to  he  performed.  Technicallv,  indeed,  iwo  ciuisiilera- 
tious  mii;lit  seeiu  to  intlui'Uce  the  ehiiice  iif  ihe  position  of  tlio  Opening. 
The  upper  porti(Ui  of  the  trachea  i>  the  most  accessilde,  but  at  this 
point  the  thyroid  renders  the  dissection  dillicult;  in  the  lower  portion 
of  liie  trachea  tin-  thyroid  does  not  interfere  with  the  dissection  but 
here  the  tiacllea  is  much  more  <leeply  situated  in  the  neck.  In  a  con- 
ti-olled  operatiiui.  howexcu',  ueithi-r  the  thyroid  aixive  nor  the  deep 
position  of  Ihe  tiachea  below  need  interfere  with  the  selection  of  that 
jHiint   which  will  h(-t  ser\-e  llu'  purpose  of  tlie  tracheotouiw     A  trans- 


132 


orKP.ATIVK    SFRGEKV    OF   TIIK    XOSE,    TTTT.OAT,    AND    KAK. 


verso  incision  Ihroiigli  the  skin  Icmvcs  llic  lu'st  ultimate  scar, — an 
important  consideration.  It  is  an  interestini-  fact  tliat,  since  folds  and 
creases  are  normally  transverse  or  oblique,  a  vertical  scar  at  once 
fixes  the  attention,  while  a  greater  scar  even  is  unnoticed  if  it  bo 
placed  obliquely  or  transversely.  A  transverse  skin  incision  i)rcsents 
but  little  more  technical  difficulty  tlian  an  ample  vertical  one.    A  con- 


FiS.  101. 
Trai-lieotomv  under  local  anesthe?ia;   novocainizing  the  skin. 


trolled  technic  so  easily  surmounts  this  o])stacle  that  the  patient  should 
whenever  possible  be  given  the  advanta.ne  of  the  transverse  incision. 

The  patient  is  first  placed  in  a  tpiiet  and  apathetic  condition  by 
means  of  a  moderate  dose  of  morplnu  or  of  morjihin  and  scopolamin. 
No  inhalation  anesthetic  is  used. 


LAinxx.  iMi.\i;v.\x.   ri'ri;i!  KsoiMiAcrs,  anm)  tkachka. 


i:]:! 


The  skin  aiul  .sulifulaiicous  tissues  aro  infiltrated  with  1 /4(M)  solu- 
tion (if  novocain.  (Fig.  101.)  'i'he  area  of  inliltiation  is  ])ut  under 
immediate  pressure  to  extend  the  anesthetie  lieid.  In  dividinj;-  the 
tissues  sharp  dis,«;eetion  oidy  is  used  and  the  field  is  kejtt  clear  and 
translucent  liy  dividing"  the  vessels  hetween  forcejis  or,  when  this  is 
imjiossible,  liy  elamiiiuy'  them  iunnediately  after  their  division. 

The  Avound  should  he  retracted  as  liiilitly  as  jiossihle.  Tf  the  line 
<if  incision  necessitates  the  ilixision  of  tlu'  tliyrnid  the  same  bloodless 
dissection  should  he  made.  If  llie  lateral  lohcs  of  the  tliyi-iiid  are 
fused  in  the  median  line  the  inland  may  lie  iiiasprd  in  foi-ceps  on  eacii 
side  of  the  ]iii>i'osed  line  of  iuei-imi  and  dixidrd.  (  Kii;.  102.)  After  com- 
])lete  division  of  the  tliyroiW  the  cut   margins  may  i)e  secured  ayainst 


Fig.  loi;. 

Tiacliootoiiiv.     Tncisidii  tliioujrh  thvroid  "iliUKl  ami  tiacliea. 


hleeiliuL;-  1iy  the  inseilion  of  l)utton  hole  stitches  with  a  curved  needle. 
When  the  trachea  is  freely  exposed  it  is  carefully  infiltrated  with 
novocain — first,  the  suiierficial  layers,  theu  .uradually  and  slowly  the 
dee]iei-  parts  of  the  tiaelical  wall, — care  being  taken  not  to  allow  the 
needle  (which  should  lie  a  line  one)  to  penetrate  bryoud  the  advanc- 
ing zoiu-  of  iniilti'atimi.  The  needle  point  siiould  always  be  in 
anesthetized  tissue  so  that  the  tracheal  wall,  including  the  keenly  sen- 
sitive mucous  menibraiu',  may  be  anesthetized  without  causing  a  single 
conuh.  Tlu'  adilition  of  adrenalin  to  tln'  no\oc;iin  solution  makes 
possible  the  Opening  of  the  trachea  without  pain  and  with  little  or  no 
oozing.  The  prevention  of  oozing  is  an  impoi'tant  i)oint,  first,  because 
blood    should   be   scrujiulonsly   excludecl    from    tin-    traelii»a    as   a  pro- 


134 


oPEr.ATiVK  sit,(;kt;v  (H-   ri:K  xosk,  •niKnAr.  and  kak. 


Icctidii  ;i<;;uiisl  sul»sci|iR'iit  iiiri'dion :  niid  -ccoikI,  liceausc  tlif  t  rickliu.t;- 
<il'  cxcn  .1  iliu|»  of  blood  down  into  llic  tr.iclu'.i  will  incite  violent  cough- 
ing and  the  strain  of  the  congliing  will  in  turn  increase  the  oozing 
becanso  of  tlie  increased  blood  in-cssurc  caused  tliei'cl)Y.  Tiiis  in- 
ci-eased  oozing  again  causes  still  more  cmighing  and  so  a  vicious  circle 
is  established.  Such  a  vicious  circle  cannot  well  be  immediately  broken 
l)y  sponging  the  blood  because  of  the  violent  motion  of  the  coughing, 
and  the  sponge  by  touching  the  anesthetized  tissue  of  the  trachea  will 
set  up  more  coughing  and  hence  defeat  its  purpose.    If  in  spite  of  pre- 


Fig.  10.",. 
Traclieotomv.     Novocahiizin!;  the  tvadiea  fiom   within. 


cautions  oozing  into  tlie  trachea  does  occur  one  can  only  wait  until  an 
adjustment  takes  place  and  the  patient  becomes  quiet. 

In  dividing  the  trachea  the  operator  may  choose  between  a  trans- 
verse division  between  the  tracheal  rings,  or  a  vertical  division  passing 
through  the  rings.  The  transverse  incision  closes  more  readily  than 
the  vertical  but  it  does  not  offer  quite  so  free  an  opening.  Trache- 
otomies performed  for  temporary  pur[)oses,  therefore,  should  be  trans- 
verse; but  for  the  long  continued  use  of  a  tracheal  tnbe— especially 
if  the  tube  is  to  be  handled  by  inexpert  liands,  the  vertical  incision 
is  better. 

As  soon  as  the  trachea  is  opened  the  mucosa  should  be  anesthe- 
tized with  a  two  ])er  cent  solution  of  novocain.  Meanwhile  the  trachea 
is  lield  oiHMi  with  such  an  instrument  as  a  small  single  liooked  tenaculum 
to  provide  for  an  abundance  of  air.     (Fig.  103.) 

The  technic  of  the  low  tracheotomy  is  the  same  as  that  for  the 


i.Ainw,   IMIAKVNX.   I  riM'.i;   KS(ini.\i;rs.   .\M>    tiiaciika. 


i:!:> 


liigli  trarlieotoniy.  It  may  he  wdl  lo  iin'iitioii  Iwn  lalhcr  siii-prisiiiii: 
facts,  liowever,  the  extraordinary  doiilli  of  ilic  trarlica  low  in  a  lliick 
neck,  a  dcptli  wliich  ajipariMitly  increases  in  a  resllcss  iiaticnt.  and 
llic  asloiii^liin;4ly  i'\lri]>i\c  cMMii^ion  of  the  li-achiM  in  \\\r  art  of 
congliinii'. 

In  this  connection  one  sees  a  rt'niaikalily  licantil'nl  dynamic  adapta- 
tion in  tile  contraction  of  tiic  varions  mnsck's  of  the  neck  to  jjrovent 
rnptnre  of  tlu'  jilenra.  AVerc  it  not  for  the  stronij  ])rotection  offered 
liy  the  neck  museies  tlic  lilcnra  at  the  apices  wouhl  snrely  lie  i-nptnred. 

Tracheal  Tube. — Amon.<;-  Ilie  many  types  of  tracheal  tnhes  tlie 
standanl  curved  metal  cannnla  consisting-  of  an  inner  and  an  outer 
tube — gives  the  best  service.    (Fig.  1"4.) 

An  albolene  or  other  oil  sjjray  applied  to  the  traclieal  mucosa  is 
an  added  protection  against   secri'tions  and  against  too  nincli  drying 


Fi-.  nn. 

TiiicliO(i(i)in_v.     .Vl'tcr  the  iijicration. 


of  the  air  which  is  now  (|epii\-ed  nf  tlie  iiiiii>liii-e  and  perliap>  warmth 
that  it  gains  in  passing  tlirongh  the  npper  ;iir  passages  in  ]U)rniaI 
lireatiiing.  At  all  e\cnts  the  liberal  nsi'  of  an  oil  s))ray  not  only  adds 
to  the  ciiiiifoi-t  of  the  patient  lint  also  lediico  till'  leiideiicy  to  dessication 
of  small  masses  of  Mincii>  in  the  iieiLihliorhiiod  nf  the  tracheal  tube. 

After-care    of    the    Patient.     The    hiiihly    eflieient    after-care    of 
tracheotomy    p;itieiit>   is   indeed   ;i   dillicnlt    .-ichievement.     There   is  an 

enormous  dilleleliee  lietweell  the  ellicielicv  of  ;|  nnise  .•ifler  expelienci' 
in  the  r[\v<-  of  t  l-;|clieiitoliiy  c;i-e>  :ilid  in  hel  lil'-t  ca-e.  It  is  well  to 
specialize  such   work.      l-"oi-  the   pro]iei-  eaic   of  hel-  patient    the  nurse 


lo(i  OPKIIATIVK.    SriHJKP.V    OK   TlIK    XOSK,    TIIIUIAT.    AXU    EAK. 

rcqnin-s  a  supjily  of  roatlicrs  tiiiiimod  doAvn  in  sucli  a  manner  tliat  tlie 
inner  tnbe  may  be  prtnniitly  cleared  of  mnens  as  .soon  as  the  j)ecnliar 
nmens  noise  is  heard.  At  first  the  patient  tends  to  become  panicky 
whenever  any  nuunis  olistruction  exists,  and  the  inex])erienced  nurse 
may  share  the  ])ati('iit  's  apiii-chension, — sun-lx  an  uiibap|iy  aliiiosplicrr. 
The  ex])erienced  nurse  k'aiiis  to  manaue  llic  imiciis  so  that  there  is 
only  an  occasional  necessity  to  remove  ami  ch'ansi'  the  tiil)e. 

'I'he  first  removals  of  the  tube  sliould  be  (hmi'  liy  the  surgeon 
since  tlie  excitement  and  the  coughing  may  <-aust'  a  ccitaiu  amount  of 
obsti'uction  which  may  tlirow  the  patient  into  a  iianic.  I'nder  these 
conditions  the  effort  to  replace  the  tube  may  increase  the  obstruction, 
cause  bleeding,  distni'b  the  local  field  and  so  do  much  harm.  Until 
the  granulations  produce  a  living  mould  of  the  tube  and  thus  guide  it 
to  its  place  it  is  Ix'st  in  r('i)lacing  the  tnbe  to  use  a  pair  of  slender 
retractors — by  means  of  which  the  opening  in  the  trachea  may  be 
brought  into  view.  The  tracluMitomy  tube  will  then  readily  dro))  into 
place. 

The  air  of  the  patient's  room  should  l)e  kejjt  eveidy  warm  and 
moist  and  may  be  medicated  by  vaporizing  pine  needle  oil.  The  moist 
air  and  a  piece  of  gauze  moistened  with  salt  solution  placed  over  the 
tracheal  tube  will  decrease  the  desiccation  of  the  secretions  about  the 
tube — and  will  maintain  a  higher  temperature  in  the  trachea.  The 
inhalation  of  cold  air  per  sc  is  not  liarmful  as  the  ordinary  cold  air 
breathing  shows;  cold  air  ma,y  produce  a  different  effect,  however, 
Avhen  one  part  of  the  respiratory  tract  is  cool  and  the  remainder  re- 
mains Avarm  just  as  one  usually  catches  no  cold  when  entirely  naked 
but  readily  takes  cold  if  there  is  only  a  partial  exposure  of  protected 
parts. 

The  tracheal  tulie  and  the  entire  wounds  should  l)e  jirotected  by 
gauze  which  should  ))e  changed  frequently.  Tlie  patient  may  sit  or  lie 
in  any  desired  ])0stnre,  though  sitting  is  usually  preferable.  The  entii-e 
che.^t  and  neck  slioiihl  at  all  times  l)e  well  covered  with  oil  over  which 
a  pneumonia  .jacket  is  ])lace(l.  Cold  drnl'ts  in  the  room  ai'e  especially 
to  be  a\'oide(l.  Xonrishment  sliould  be  well  maintained.  It  is  most 
inqiortant  to  keep  the  wound  free  I'lom  pus  accnmulation  because  the 
iidialation  of  wound  discharges  is  a  distinct  danger.  Tf  there  is  no 
contraindication,  such  as  an  exi.sting  obstruction,  it  is  well  occasionally 
to  remove  the  tuiie  for  a  time,  especially  if  the  ])atient  is  fretting 
about  the  irritation,  if  th<'  general  precautions  ai'e  sci-u])ul()usly  ob- 
sei-ved  the  great  danger  of  ti-acjieotomy,  ti'acheobronchopuimonary  iii- 
Tection  may  be  avoided. 

it    has    been    an    agreeable    sni-i)i-ise   to   obsei've   the    facililv   with 


i.AnvNX".  riiAinxx.  i  tpki;  ksoimiaci's,  anh  tiiaciika.  137 

wliicli  itiilioiits  cari'  for  tlicii-  I  lacliciil  IiiIk-s  .iritT  llicv  lijivc  hccoiiu' 
;ul.jii>(>'tl.     It    is  doiu'  as  a    iiialliT  of   iDuliiic  ami    with    tlic   |ir<'cisi<»ii 

acr()in|iaii\  iiiu  aii>  olliri'  ili'Inil  nl'  lln'  ilaily  toilet.  TIh'  aiitiioi'  has 
had  palii'iils  rrtaiii  Irai'liciiloiny  liilics  for  a.-  Inii.n  ii>  twcKc  years 
liel\ire  tile  ()|iellillL;-  was  closed. 

Closure  of  a  Tracheotomy.  The  ultimati'  closun'  of  a  tradu'otDiiiy 
i>  ea>ily  aecoitiplished.  The  entire  ^rai-  i>  hloodlcssly  .se])arat('d  ri-i»iii 
tlio  iioniial  tissues  sun()Uiidin.n-  it  .just  as  tlu'  scar  is  dissected  out  in 
a  case  of  lu'vuia  t'ollowiuu'  alidouiiual  di'ainauc.  AVlicii  tlic  dissoctiou 
lias  reaclie<l  the  tracheal  wall,  the  inliltration  with  no\cicaiii  and 
adivnalin  is  niuiit  carefully  extended  throuiihout  the  hasal  altacliuient 
of  the  scar  before  the  separation  of  tin-  scar  is  attomptotl.  After  the 
excision  of  the  scar  the  soft  jiarts  can  very  readily  he  hrouii'ht  loi;-ether 
into  their  normal  relation  in  the  nie<lian  line.  It  i-  unnecessary  to 
suture  the  trachea  dii'i'ctly  hecause  on  the  release  of  the  >car  the  ])arts 
will  show  a  surprisiuii"  tendeney  to  fall  toii'ether  e\-eu  after  many  years 
of  separation.  The  anllmi-  has  found  that  the  wnund  heals  l)y  first 
intention  and  that  afterward  there  does  not  remain  a  dimple  or  a 
de]ire»ion  e\en.  If  the  oriuiual  skin  incision  was  tranverse  there 
will  soon  he  no  noticealde  scar  to  mark  the  place. 

The  cases  in  which  the  ti'acheal  tuhes  were  worn  louLicst  were 
those  in  which  there  were  larynx  lilliui:-  papillomata  in  little  children. 
In  thri'e  >nch  ca>es  a  >ncce;-sful  i-sne  wa>  linall\-  reached  in  one  after 
twelve  years,  in  another  after  nine  years  and  in  the  third  after  fonrteen. 
The  ]iatients  Avere  inspected  at  \aiions  intervals.  Particularly  note-  • 
worthy  was  a  case  of  Dr.  W.  If.  Lincoln  in  which  after  fourteen 
years  the  larynx  was  found  to  lie  free.  The  tracheal  trad  was  then 
closed.  Duriuii'  this  time  the  larynx  i;-i-ew  normally  tlionL;h  it  had 
heen   hut   slii^'htly   u-ed. 

Cicatricial  Stenosis  of  the  Trachea.-  Cicatricial  stenosis  of  tiie 
trachea  usually  follows  syphilitic  ulcerations,  dec\iliitns  from  weariuir 
intubation  tubes,  and  ulceration  from  other  causes. 

This  condition  presents  a  very  difficult  piohliMu.  If  the  trachea 
lie  opened  merely,  the  scar  dissected  out  a-  neally  as  iiossible,  and 
the  trachea  then  closed,  recurrence  is  ipiite  sure  to  occur.  Dissection 
followed  liy  the  iiiseition  of  a  tulie  i;i\-es  no  better  results.  Tlie 
presence  of  the  tulu'  appai'eiitly  increasi's  the  i-eaclion  wliicli  is 
marked  hy  the  formation  of  even  more  scar  tissue,  in  tlie  antiior's 
opinion  there  i-  hut  little  hope  in  any  metho<|  except  in  resection  of 
the  trachea.  This  ojieration  offers  at  least  one  formidai)le  dinicuKy 
— the  surprisinsfly  <rreal  elastic  retraction  of  the  trachea  toward  the 
lun.U'.  which  exists  even  in  the  (piiescent  state,  is  .greatly  incri'ased  hy 


l.'JS  orKltATlVK    sriKiKUV    OK   TIIK    XOSE.    Tl  I  111  >AT,    AM)    KAU. 

cougliiii.t>'.  Tliis  rctiiU'lioii  of  coui'st'  throws  a  licavy  sti'ain  on  tlio 
stitches  and  on  the  lini'  of  lioahnij'.  This  diniculty  can  1)0  met  hy  the 
nso  of  lualtvoss  stitches  of  silver  wire  which  incUule  in  their  grasp  a 
ring  ol'  the  trachea  above  the  stenosis  and  one  beloAV  it.  A  good 
(•h)snre  is  seen  red  by  inserting  three  such  silver  wire  mattress  stitches, 
one  on  eacli  lateral  side  of  the  esophagns  and  one  in  front,  leaving  the 
free  end  long  so  that  it  emerges  freely  from  the  wound.  By  twisting 
these  wire  sutures  the  apposition  of  the  trachea  is  readily  secui'ed. 
This,  of  cour.se,  can  succeed  only  when  the  trachea  is  ({uite  normal. 
If  the  rings  are  soft  or  the  tracheal  wall  edematous,  the  method  can- 
not succeed. 

In  one  of  the  author's  cases  the  tracheal  wall  was  in  such  poor  con- 
dition that  the  sutures  could  not  hold  and  it  was  necessary  in  the  end 
to  resort  to  a  permanent  tracheal  tube.  Fortunately  there  are  not 
many  of  these  cases. 

Surg-ery  of  the  Larynx. 

Laryngectomy  for  Intrinsic  Cancer. — The  legitinuicy  of  operation 
upon  any  part  of  the  body,  especially  those  parts  the  damage  of  which 
may  cause  immediate  danger  to  life,  depends  upon  the  answers  which 
can  be  given  to  three  vital  questions:  Will  the  operation  result  in 
the  cure  of  the  disease?  Can  the  risks  be  overcome?  What  will  be 
the  extent  of  permanent  disability?  So  uncertain  until  yo\y  recent 
years  have  been  the  ansAvers  to  these  questions  as  applied  to  laryn- 
gectomy for  cancer,  that  it  is  not  strange  that  the  operation  is  one 
of  the  most  recent  developments  in  surgical  history,  having  been  first 
performed  by  Billroth  in  1874. 

Even  after  surgeons  had  become  convinced  of  the  possibility  of 
the  cure  of  intrinsic  laryngeal  cancer  by  this  means  it  was,  and  is  still, 
most  difficult  to  persuade  patients  to  submit  to  it — the  instinctive  objec- 
tion to  deep  throat  operations  being  the  natural  outcome  of  the  expe- 
riences of  the  far  distant  past  when  the  throat  was  the  point  of  attack 
in  our  carnivorous  evolutionaiy  ancestors,  and  it  being  still  the  part 
most  liable  to  danger  in  hand-to-hand  conflict. 

Does  laryngectomy  for  cancer  result  in  a  cure  of  the  disease? 
Ul)on  our  answer  to  this  depends  the  need  for  considering"  the  other 
two  questions.  We  still  accept  Krishaber's  classification  of  lar\aageal 
cancer  as  intrinsic  and  extrinsic.  As  the  tenn  implies,  intrinsic  laryn- 
geal cancer  starts  within  the  larynx  itself  in  the  vocal  cords,  the  ven- 
tricular bands  or  the  parts  below;  while  the  extrinsic  form  starts  in 
the  epiglottis,  the  arytenoids  or  other  parts  outside  the  larynx  proper. 
Intrinsic  cancer,  then,  is  contained  within  a  hyaline  cartilage  box,  and 


l.AI'.VNX.     l'll.\i;VX\,     llM'I'.l!    ESorilAllCS,    ANM)    TKAC'I  I  I'.A.  l->.' 

is  ill  largo  iiioasun'  cut  nil'  I'ldin  the  |>iissiliilit y  of  lyiuiilmlic  iiivolvo- 
iiionts;  \vliil(^  the  oxli'iiisic  I'diiii  i:i(i\\>  i-;i|iiilly  ;iiiil  c.-iii  (■.■i-ily  and  early 
t'Xti'iid  tliruimli  till'  lyiii|ih  cliaiiiii'ls. 

Marly  (iiai;iin>i>  and  rrninxal  i>  llir  kcyimti'  n\'  NalVty  in  cani-ci-- 
oiis  urowtlis  aiiyw  lii'i-i',  and  laryngeal  cancer  makes  itself  knnw  n  alinrist 
at  (iiice.  since  IVoni  its  xcrx  lieuinninL;  tiie  |ii(ilialiility  nf  its  |ii'eseni'i' 
beciiines  evident  in  the  persistent  Imar-e  Noiee  of  the  patient.  We  may 
say  then,  that  intiinsie  laryngeal  cancer  exists,  as  it  were,  in  a  safe 
deposit  hnx.  It  early  aniioiincos  its  preseiiee  and  has  Imt  I'eehle  power 
of  exti'nsixc  inxasion  <>r  i>\'  metastasis.  We  cdnclnde.  t  liei-e|ni'e.  that 
this  form  nf  cancer  <i\'  the  lai'ynx  is  cui-alile  li>'  excisicm.  Kxtiinsic 
cancer,  nw  \\]r  cithei-  han<l,  is  rapidl)'  fatal,  and  dpeiatidii  fur  its  relief 
is  at  best  but  a  desperate  remecly. 

What  is  the  surgical  risk:'  'i'he  author  has  lieil'iunied  twenty- 
seven  larynu'cctomies  for  cancel-  with  twn  uperatixe  fatalities;  one 
death  resulting  fmm  mediastinal  ahscess,  the  ntlier  IVnm  necrosis  of 
the  trachea  with  a  cnn^eipient  septii'  pneuninnia.  This  makes  a  nnu'- 
tality  rate  of  se\'en  plus  per  cent,  a  rate  w  hicli  cnmpares  faxurably  with 
that  of  excisions  I'or  cancer  of  the  tongue,  of  the  stomach,  and  of  the 
rectum. 

What  is  th<'  permanent  disability  of  the  patient.'  Those  priiici- 
jially  feai-ed  are  im|iairment  of  speech,  disliguremeut,  and  a  predispo- 
sition to  pulmonary  diseases  and  accidents.  As  to  speech  impairment, 
all  ])atients  ac<|uire  a  buccal  whisi)er  wliich  serves  the  ])uriiose  of 
speech  remaikably  well.  ( )ne  of  the  author's  patients  is  at  the  head 
of  a  large  industrial  corjioi-ation:  another  is  a  judge;  another  is  fore- 
man in  a  i^nblic  works  de|)artmeiit;  another  became  a  popnhir  barber; 
still  another  is  managing  a  small  coal  sales  agency;  one  housewife  ap- 
parently gets  on  well  enough;  and  a  fai'iuer  has  managed  his  flocks  and 
his  teams  in  silence.  The  speecii  defect,  to  he  sure,  is  great,  liut  it  can 
be  compensated  for  to  a  remarkable  degree  liy  tiie  de\i'lopment  of  the 
buccal  whisper,  the  use  of  gestures  and  other  foi-ms  of  primitive  lan- 
guage, and  by  the  adaptation  of  those  indi\iduals  who  comh'  into  dailv 
contact  with  the  patient. 

Tile  disligui'ement  max  lie  well  coNcied  liy  wearing  various  kinds 
of  cra\ats  or  neckwear  anangecj  in  such  a  manner  as  to  allow  free 
breathing,  and  at  the  ^ame  time  to  diminish  the  sihilant  sounds  of  the 
changing  air  ciiii-eiits. 

As  to  the  predisposition  to  accident  and  disease,  to  the  author's 
knowledge  there  has  heen  no  instance  of  a  foi'eign  liodx-  in  the  resjjira- 
tory  tract  of  any  of  his  lary nui'ctomized  patients,  nor  has  there  been  a 
single  case  of  pneumonia.     .\ot    onl\-   lia\e  his  patii'iils  shown   no  leu- 


140 


(ii'KiiATivK  sri;(;i:i;v  of  the  xose,  throat,  axd  ear. 


(li'iii-v  ti)  piR'umoiiia  aii<l  hroiicliilis,  Imt   tlicy   liaxc  liccn   icin;nkal)lv 
h\'v  i'roiii  nasal  colds. 

Wo  may  coiiclnde,  then,  in  answer  to  our  Ihlrd  (luestion,  that 
tlionii'li  tlio  disal)ility  resnltinn'  from  laryniicctoiny  is  tii-cat  yot  it  Is 
fairly  well  conipensated  for. 

Some  years  at^-o  the  author  made  an  interesting  stndy  of  the  laiyn- 
gectomies  reported  in  the  medical  press  from  1874  to  1901.  A  snmmaiy 
of  the  statistics  gives  significant  results.  From  1874  to  1876,  12  lar- 
yngectomies for  carcinoma  were  reported  with  one  ultimate  cure,  mak- 
ing the  percentage  of  ultimate  cures  8.33.  From  1876  to  1886,  108  lar- 
yngectomies, 21  ultimate  cures,  percentage  of  ultimate  cures  19.44. 
From  1886  to  1896,  156  laryngectomies,  49  cures,  percentage  of  cures 
23.82.  From  1896  to  1901,  30  laryngectomies,  20  cures,  percentage  of 
cures  66.67.  The  causes  of  death  as  i-eported  are  those  w^ith  which  we 
still  are  contending,  but  which  improved  technic  has  helped  us  in  large 
measure  to  meet.  Indeed,  the  figures  just  given  show  the  increasing 
confidence  of  surgeons  and  patients  in  operative  relief  for  this  distress  - 
ing  disease,  a  confidence  well  su])ported  by  the  rapidly  decreasing 
mortality  rate. 

Anesthetic  in  Laryngectomy. — Before  jiroceeding  to  the  detailed 
technic  of  laryngectomy,  some  special  statement  should  be  made  I'e- 
garding  the  manner  of  administering  the  anesthetic.  It  should  be 
borne  in  mind  that  the  administration  of  the  anesthetic  should  be  so 
planned  that  the  operator  may  be  unhampered  in  his  technic,  that  the 
anesthetist  may  give  an  even  and  safe  anesthetic,  and  that  there  may 
be  no  inhalation  of  blood,  wliile  the  choice  of  the  anesthetic  itself  is  a 
most  important  factor.  Our  general  anesthetic  of  choice  is  nitrous 
oxid-oxygen.  The  patient  already — it  is  presumed — in  fear  of  the 
possible  suffocating  results  of  a  laryngeal  operation,  takes  this  anes- 
thetic without  the  terrifying  suffocating  symptoms  caused  by  ether, 
and  is  quickly  under  its  influence  without  a  struggle.  We  have  proved 
also  by  laboratory  investigations  tliat  while  nitrous  oxid  does  not 
alter  the  immunity  of  the  patient,  ether  on  the  other  hand  tends  to 
impair  the  immunity.  Since  nitrous  oxid-oxygen,  however,  should  be 
given  by  the  trained  anesthetist  only,  the  following  technic  is  equally 
applicable  to  the  administration  of  ether.  In  our  discussion  of  medi- 
astinitis  we  have  described  the  preliminary  tracheotomy  by  means  of 
which  the  trachea  has  become  firmly  fixed  in  its  position.  (Fig.  105.) 
At  the  time  of  operation  the  tracheotomy  tube  is  removed  and  a  well- 
lubricated  snug-fitting  rubber  tubing  a  foot  or  more  long  is  slowly  and 
carefully  slipped  into  the  trachea.  The  rubber  tubing  being  slightly 
larger  than  the  trachea,  the  latter  is  dilated  and  tlie  rubber  tube  com- 


L.\i;VXN,     I'llAKVNX.     IIM'KK     i;S{  >IM  I  ACTS,    AND    TIIAl'l  I  K.A.  14! 

pressed,  so  tlial  ;i  liiiiil  liulit  lit  results,  l^y  this  menus,  llie  eiiti-aiu'e  of 
any  blood  into  the  res|iii;itni\  tr.ift  is  |ii-<'\ciiled.  iVlv:.  Kxi.)  The 
long  piece  of  nililier  tiiliiiiu'  iiiiiy  then  lie  attached  In  the  nitrons  oxid- 
oxygen  apparatus,  or  it  may  be  Joined  to  a  special  apparatns  consist- 
ing of  a  funnel  covered  witii  gauze  upiui  w  liieh  ether  may  lie  di-o|)ped. 
By  this  arrangement  the  anesthetist  is  at  a  ilistanee  iVnni  the  licld  of 
oiM'i-atinn   and   is   nnliani|  lered    hy   the  (iperatdi-.   while   Ihi'   n|ii'r;itiir  on 


his  si(h>  is  nnhani|ieii'i|  hy  the  anesthetist.     There  re-nlts  an  e\en  anes- 
thesia and  tile  1mv-i  (ip|Hii-tnnit\-  \\<i  a  well  edntruUed  operation. 

'I'll  pi'e\cn1  iKieiiniis  iiiipulse-  IVnni  the  liehl  of  operation  I'rom 
reaching  the  brain,  and  a-  a  pinleet  inn  aiiaiiist  the  excitation  of  special 
reflexes  tlirough  tlie  mechanical  st  iinnlatinn  nf  the  trunk  or  terminals 
of  the  sui)ei-ioi-  laryngeal  ner\e>.  nnxin-ain  is  used  as  a  local  anesthetic. 
The  maimer  of  its  administratinn   will   he  given  in  the  description  of 

the  opel-ati\e  fechnic. 

Technic  of  Laryngectomy,     l-'irst  the  skin  is  tliornugldv  iufiltratod 


142 


(ipI':i;ati\I':  sikoi'.kn   (tv  ttte  xosh,  "rniKiAT,  Axn  kai;. 


with  novocain  alon^-  the  median  lino  from  a  point  al)ove  the  liyoid  bone 
to  the  tracheotomy  ojjoning-.  Tlie  tissues  are  divided  down  to  the  box 
of  the  laiynx,  the  divisions  of  the  platysma  and  of  the  other  soft  parts 
being-  preceded  also  bj-  novocain  infiltration.     The  dissection  is  then 


Fig.  100. 
Laryngectomy.      Five    days    after    proliniiiiarv    traelieotciiny.      Arrange- 
ment of  tulie  for  anesthesia. 


carried  down  along  the  lateral  aspects  of  the  larynx  until  the  larynx  is 
completely  freed.  If  there  is  lack  of  free  working  space  at  the  upper 
end  a  lateral  incision  is  made  parallel  with  the  hyoid.  The  thyrohyoid 
muscles  above  and  the  sternothyroid  muscles  below  are  severed.  So 
far  as  its  muscular  attachments  are  concerned,  the  larynx  is  now  com- 
pletely mobilized.     If  the  laryngoscopic  examination  has  iixed  accu- 


LAiaxx,  i'iiAi;vNX.   I  ri'Ki;  KsoiMiAcrs.  axp  thaciika.  14.'! 

vntoly  tlio  limits  of  tlu'  ii('(i|ilasiii,  the  li'\-cl  of  the  division  of  the  hiryiix 

IlKiy    he    |irc(lcti'l-lllillc(l,    ;ill(i    lllc    lli'Xl    slr|i    will    lie    lilc    ilivisioil    of   tllG 

trachea  oi-  the  ri-i,-oii|  at  a  li'\cl  five  !iiiiii  .li>ca>c.  I'-i'Toiv  lliis  last 
(lix'isioii  i>  iiiaiii'.  Ikiwcmt,  iioxdcaiii  i>  inlilt  ratrd  into  llir  iiiiicosa 
tlirou.u'iiout  till'  entire  leimtli  of  the  pidjiosed  division.  I*>,v  this  means 
the  tei'niinals  of  the  sniierior  larvn^eal  nerxcs  are  completel)  hlocj^cd 
and  the  mu<-o>a  ma>  he  diviih'tl  and  the  larynx  opened  withoni  ean^inu' 
a  chan.nf  in  the  resjiii-ation  or  the  circulation.  IT  the  patient  is  old 
and  till'  cartiia.^c  is  ossified  it   is  necessarv  to  exei'1   the  ,iii'eat<'s1    pre 


Fi-.   nj7. 
I.:nynKoctoiii_v.     S(>jiai;Ltiiiii  of  tlic  lumix  fnnii  the  csopliajitus. 

caution  in  dividino'  the  larynx  in  order  that  the  csoplni.n'us  may  iH)t 
l)e  iii.iui'ed.  The  (li\"ided  end  of  the  larynx  is  next  raised  up  and  the 
attaclnncnt  Ix'twoen  the  larynx  and  the  esoijhajLifus  is  divided  with 
knit'o  or  scissoi-s.  (  l-'iu.  Iii7.)  In  a  shoit,  thick  neck  tlie  wings  of  the 
larynx  wjiich  extend  down  laterall>-  to  pi-otect  eacii  side  ol'  the 
('S()pliafi'»>.  ai'e  di\ided  with  >ci.-sor.-.  'i'lie  dissection  is  then  cari'ied 
upward  until  the  uppei-  end  of  the  larynx  is  leached,  whei-e  its  pos- 
tei-ior  wall  liecome>  I'u.-eil  with  Ihe  anteiior  wall  of  the  phar\  nx.  The 
upper  end  of  the  lai'Nnx  i>  then  cut  \'\-i'r.  the  lari^ei-  artei'ies  heing- 
severed   at    the   Ncrv    last.      llemo>ta.'~i>   mii.-t    Ik-   nmst    tiior()nu:hlv   ob- 


144 


oim;i;a'i-ivk  snicKuv  or  ttte  xo.se,  tiikoat,  and  ear. 


served  t  lirouuhoul  Hie  opei-.-it  ion.  If  the  caiicei-  is  iiiti-iiisic  llie  lyiii- 
])Iiatic  .liiainl,-  w  liicli  ilraiii  1  he  diseased  /.(iiie  slioiild  he  careriilly  lemoxed 
with  the  hiryux  itself. 

Two  iiiipoi-tant  questions  now  ai-ise  repaid  in,:;  the  nianiiei'  of  ileal- 
in.i;-  \\ilh  the  wound:  (1)  What  sliall  he  done  with  the  end  of  tlie 
tnu'hea .'  and  {'2)  Shall  flie  entire  wound  of  the  neck  he  cIoxmI  .'  As 
to  the  trachea,  there  are  two  alternatives:  It  may  l)e  freed  suffieienlly 
to  hrinp,-  it  forward  and  stiteli  it  to  tlie  skin,  oi-  it  inav  l)e  left  where 
it  lies,  exceptin.t;-  at    its  very  nj)]'ei-  end,  which   may  he   heiit    forward 


Fig.  108. 
Liuyngeetoiiiy.     Clo.sure  of  ]iliaryngeal  opening 


and  sewed  to  flaps  of  skin  hrought  down  from  each  side.  The  advan- 
tage of  the  first  method  is  that  by  this  means  the  trachea  is  protected 
from  the  inhalation  of  wound  secretion.  The  disadvantage  is  the  very- 
definite  possibility  that  the  loss  of  )>lood  snpply  may  resnlt  in 
gangrene  of  the  trachea.  This  did  occur  in  one  of  the  author's  cases. 
The  objection  to  leavini;-  the  trachea  in  its  natural  bed  and  transplant- 


i.AinxN,   ruAin  \\.   rrri:i;   v.soniAins,  and    iiiaciika. 


14:, 


ing  to  it  llic  -kill  l!;i|w  is  tiif  I'm-t  tluit  wouiid  si'ci-cf inn  will  almost 
cortaiiil}'  ciitcr  il.  \'>y  i:i\iiii;  tin-  wnuiid  ;ii|i'(|iiatc  can',  lidWcN-cr.  this 
clanger  may  lie  axoidcil. 

As  to  tlic  care  of  tlic  M'sI  n['  tlic  whuikI,  lln'  aiillinr's  Ix'sl  pro- 
codnro  has  boon  to  sutui'c  tlu'  o|H'iiiiii;  in  I  ho  |ihar\n\  and  (Fig.  108), 
if  possible,  to  roonfoi'co  tiiis  siitiin'  by  diawiii:^  dthci-  suit  jtarts  togotlier 
over  it.  Tlie  rest  of  the  tidd  is  Icl'i  ii|mmi.  liciim'  paidvcd  lightly  with 
iodofonn  ganzo.  ( I'ig.  UH'.)  \\'ith  sm-li  a  wide  open  wound  the 
secretions  may  bo  easily  (•iiiilrnlli'il  and  pri'vcntrd  tiDni  entering  the 
trachea.     The  )ia1ieiil   shouhl    he  sustained   hy  the  fullest  diet  he  can 


Fig.  l(li>. 
Lai'viifiectomy.     Closiup  of  wouiul   with   iudofm-in   giui/i'   pac-kiiig. 

1)0  made  to  take,  and  by  inost  carerul  iiiirsiiiu-.  The  sutures  in  the 
))liaiynx  may  not  laild,  hut  the  fnniiidahle  biokiui;-  wound  will  close 
\-ery  readily  by  mainilatidii  and  emit  ractioii. 

liai-yugeetdiny  is  fnlhiwed  usually  by  a  brisk  hieai  reaction;  l)ut 
since  the  mediastinuni  has  been  prnteeted  by  the  ]ii-eviiius  gauze  pack- 
inii',  and  the  bi-oiichopuhnonary  tract  has  bot'u  given  a  special  defense 
l)y  the  prcdiminary  ti'acheotoniy,  the  ])ationt  is  well  ei|uippod  to  meet 
the  new  cdnditinii. 

In  the  autlmr's  1  w ciity  sexcii  laryimectdiiiies  there  wore  two 
di'atli-,  and  these  twci  were  appaii'iitly  the  most  promising  cases  of 
all.     The  pid-iiosi-  in  t  he.-e  cases  seeinecl  sn  I'avMH'able  tliat   1h(>  author 


14()  OI'KIt.VnVK    SURGERY   OF   TTIE    XOSK,    THROAT,    AXD    EAR. 

veiitnivd  to  discavd  the  full  preliminary  preparations.  In  one  case 
no  preliminaiy  ])rotective  operation  of  any  kind  was  made  and  the 
patient  died  at  the  end  of  five  weeks  with  mediastinal  abscess.  In  the 
other  case  a  preliminary  gauze  packing'  was  placed  in  the  neck  around 
tlie  ti-nchea.  but  no  preliminary  tracheotomy  was  performed.  In  this 
case  the  isolated  ui)i)er  end  of  the  trachea  was  brought  forward  to  the 
skin  and  anchored.  The  entire  isolated  ])ortion  necrosed,  as  did  also 
a  portion  of  the  trachea  beyond  the  isolated  ])art.  As  a  result  pus  was 
inhaled  into  tlie  respiratory  tract  below  the  level  of  the  sternum.  An 
autopsy  showed  no  pneumonia  and  no  mediastinitis,  but  a  septic 
tracheitis  and  bronchitis.  Death  was  the  result  of  local  absorption, 
and  of  absorption  from  the  trachea  and  from  the  bronchial  mucosa. 
This  case  demonstrated  most  conclusively  the  efficiency  of  the  granu- 
lation barrier  which  is  created  by  a  pi-eliminary  iodoform  packing. 
Had  a  preliminary  tracheotomy  been  made,  or  had  the  trachea  been 
allowed  to  remain  in  its  bed,  the  patient  would  surely  have  recovered. 
In  sixteen  of  these  twenty-seven  laryngectomies  for  cancer  the 
laryngeal  box  was  so  choked  Avith  the  growth  that  tracheotomy  was 
required  to  prevent  suffocation.  Most  of  the  author's  patients  gave 
a  long  history  of  hoarseness  followed  by  gradual,  though  intermittent 
obstruction  to  respiration.  In  two  cases,  there  was  associated  lues. 
One  of  tliese  last  two  cases  illustrated  well  the  clinical  difficulty  of 
diagnosis.  The  lesion  was  first  diagnosed  correctly  as  luetic,  and 
under  a  course  of  treatment  the  greater  part  of  the  growth  disappeared. 
The  residual  growth,  however,  showed  a  progressive  tendency,  and 
Avas  later  diagnosed  as  cancer.  Laryngectomy  was  performed  and  the 
patient  is  now  alive  and  well,  more  than  three  years  since  his  opera- 
tion. The  si^ecial  lesson  from  this  case  is  that  cancer  of  the  laiynx, 
like  cancer  of  the  tongue,  may  follow  local  luetic  lesions.  There  is 
dangei-,  therefore,  that  the  hope  of  a  luetic  cure  may  defer  too  long 
the  laryngectomy  which  is  the  only  chance  for  the  cure  of  the  cancer. 
Extrinsic  Cancer  of  the  Larynx. — As  ali'eady  stated  extrinsic  ean- 
(•(']■  of  llie  larynx  ])resents  a  diiferent  and  a  more  desperate  problem 
than  does  intrinsic  cancer.  Extrinsic  cancer  is  more  difficult  to  attack 
on  account  of  its  ])osition;  it  is  disseminated  earlier  and  more  widely 
on  account  of  the  greater  muscular  activity  of  the  parts  involved.  Ex- 
trinsic cancer  of  the  larynx  is  however  more  accessible  than  cancer 
of  the  tonsil  or  cancer  of  the  pharynx.  The  same  considerations  apply 
to  cancer  of  the  base  of  the  tongue. 

In  attacking  cancer  here  a  prelinunary  tracheotomy  is  essential, 
wide  neck  incisions  are  made,  the  cancer  is  exposed  most  cautiously 
and  is  thoroui^hlv  thermocauterized.     In  the  further  dissection  great 


i.ai;yxx,  PiiAnvxx,  itpki:  ksopiiaccs.   and    rKAciir.A.  147 

ctivo  must  1)0  oxorcisod  not  (n  ili-^tiirli  the  cscli.'ir.  At'lcr  cninijlrli'  mid 
wide  excision  of  tlic  cniiciT  tlir  wcniiid  sliouhl  lie  li'ft  wide  npcn  for 
llic  free  use  of  the  X  ray. 

In  one  instnnce  tlu-  autlidi-  cxi-iscd  the  liasc  n\'  the  ton.i^ne,  the 
pillars  of  the  jtharynx,  tiie  i)liarynx  itself,  Uic  entire  laiynx,  tlie  hyoid, 
— in  short  all  of  the  tissues  lyin.c,"  between  the  jmictnrc  of  the  jiosterior 
and  the  middle  third  of  the  tong-ue,  the  uppi-i'  riiii;'  of  tlif  trachea  and 
the  upper  end  of  the  esophas'us.  leaviii.i;  Uul  a  .-li^lit  covi-riiif;-  of  tiie 
vertebrfp.  This  enormous  wound  looked  hopeless  for  a  long  time — 
durinu-  which  the  X-ray  was  used  freely — but  finally  closed  completely. 

About  four  years  later  metastasis  developed  in  one  of  the  sub- 
maxillary lymphatic  .ulands.  "When  the  author  saw  it,  this  gland  was 
(piite  large,  was  inflamed,  huggeil  tlie  jaw  elosely  and  involved  the 
swollen  reddened  skin  coveiing  it.  Again  a  wide  excision  was  uuidc, 
so  extensive  that  the  wound  couhl  iH)t  have  been  closed  ha<l  the  author 
so  desired.  The  X-ray  was  used  fi-eely  during  \ho  iiroeess  of  healing. 
The  lower  jaw  was  so  closely  hugged  by  the  cancer  that  about  one- 
thiril  of  tht>  jaw  was  sawed  off  longittidinally — the  sawed  fragment  of 
bone  coming  olV  with  the  rest  of  the  caiu'cr.  Tn  due  time  the  wound 
was  skin  grafted  and  closed.  It  has  Keen  oxci-  li\-e  years  since  this 
last  operation  and  nine  years  since  tlie  first.  The  ])atient  is  now  at 
work.  He  speaks  with  a  sort  of  a  buccal  whisper, — is  able  to  sAvallow, 
to  drink  and  to  smoke  with  ease  and  comfort. 

This  case  taught  the  author  that  no  one  can  tell  when  a  case  is 
hopeless — for  surely  this  patient  seemed  to  be  in  a  hopeless  condition. 
The  repair  of  the  mutilations  ])roduced  by  this  operation  in  which  so 
many  iniijortant  structures  were  removed  and  the  consequent  recovery 
have  been  a  source  of  encouragement  and  inspiration  ever  since. 

Tn  another  case  of  extrinsic  cancer  the  operation  in  a  local  lield 
was  not  so  extensive  but  the  lyni))hatic  involvement  was  much  greater. 
Tn  this  case  the  growth  had  so  filled  the  larynx  that  the  obstruction 
lia<l  (■anse<I  asphyxia,  as  a  result  of  which  the  ])atient  had  fallen  njion 
the  street.  An  emergency  tracheotomy  was  performed,  at  which  time 
one  of  the  h^mphatic  glands  was  removed  for  diagnosis.  At  the  later 
operation  the  exci.sion  was  carried  laterally  so  as  to  include  the 
lymphatic  gland-bearing  tissue  on  both  siiles,  all  of  which  was  removed 
fH  hloc  with  the  larynx  and  the  base  of  the  tongue.  The  ]iatient  is 
well  and  hale  seventeen  years  after  the  operation. 

Stenosis  of  the  Larynx. — Stenosis  of  tlu'  lai-ynx  may  bo  due  to 
intubations — now  infi-iMiuently  done — or  io  ulcerations  which  are 
usually  syphilitic.  Tjike  stenosis  of  the  trachea  -already  described — 
stenosis  of  tlio  larynx  is  an  exceediniih-  formidable  condition. 


148  orEnATiVE  sri;(;i:i!Y  of  the  nose,  thuoat,  and  ear. 

The  author  has  attoinptcd  to  open  tlie  hii-ynx  by  splitting  it  ver- 
tically, dissecting  out  the  scar  and  tlien  resutnring  the  incision,  but 
the  stenosis  recurred  so  proiiijitly  thnt  Ihc  patient  was  denied  tlie  com- 
fort of  a  goodly  respite  even. 

Tn  another  instance  the  autiior  did  a  heiiiilaiyngegtomy  in  the 
hope  that  the  larynx  might  adapt  itself  as  it  may  (hi  in  lieniilaTyngec- 
tomy  for  cancer — but  this  did  not  afford  a  ])ermaneiit  air  space. 

Tn  another  case  the  larynx  was  opened  wide,  the  sear  was  com- 
]jletely  dissected  out  and  an  attempt  was  made  to  cover  the  raw  area 
innnediately  with  large  and  accurately  placed  skin  grafts.  The  re- 
spiratory tract  and  the  grafts  as  well  were  protected  by  a  trache- 
otomy. Despite  the  utmost  care  tlie  grafts  did  not  grow.  For  a  time 
they  did  well,  but  the  patient  was  a  child  only  four  years  old  and  hard 
to  control.  The  author  gained  the  impression,  however,  tliat  were  it 
an  adult  case  and  the  skin  grafts  autodermic  they  might  have  held. 
Even  then,  however,  one  could  not  be  certain  that  the  scar  might  not 
again  contract.  Tn  a  child  with  stenosis  of  the  cricoid  referred  to  the 
author  by  Dr.  W.  B.  Chamberlain,  an  attempt  was  made  to  remedy  the 
stricture  by  resecting  the  lower  end  of  the  cricoid  and  suturing  the 
trachea  and  the  divided  cricoid  together  by  means  of  silver  wire. 
The  resection  of  the  strictured  cricoid  was  easily  accomplished  but  as 
the  trachea  was  so  much  smaller  it  was  difficult  to  bring  it  into  pre- 
cise tubular  apjiosition.  Although  a  union  was  secured  the  stenosis 
was  not  relieved  and  the  author  was  obliged  to  resort  to  a  permanent 
tracheal  tube.  With  our  present  means  the  author  is  unable  to  see 
much  hope  in  operations  for  strictures  of  the  larynx.  Tn  one  case 
massive  scar  tissue  firmly  fixed  to  the  box  of  the  larynx.  Tn  one  case 
the  use  of  thiosinamin  was  added  to  the  operative  procedure,  but 
apparently  its  influence  was  nil. 

Surgery  of  the  Pharynx  and  EsophagTis. 

Cancer  of  the  Pharynx  and  Esophagus. — Hitherto  cancer  of  the 
esophagus  and  of  the  pharynx  has  not  lieen  attacked  as  successfully 
as  cancer  in  many  other  parts  of  the  body.  AVlien  dealing  surgically 
with  cancer  in  these  regions  it  is  important  to  bear  in  mind  that  if 
cancer  cells  become  lodged  in  the  fresh  wound  they  are  not  only  likely 
to  grow,  but  to  grow  with  even  greater  vigor  than  in  the  original 
lesion.  There  is  not  an  abundance  of  experimental  evidence  to  support 
this  statement  but  ample  clinical  proof  is  not  lacking.  The  experi- 
mental evidence  that  is  especially  pertinent  is  the  following:  If  a 
piece  of  cancer  tissue  from  a  dog  is  rubbed  on  an  abraded  surface  of 
the  skin  of  another  dog  a  cancer  is  likely  to  develop  from  the  cells 
which  became  detached  and  lodo'ed  on  the  denuded  surface. 


i.Ai;vxx,  niAnvxx,  irpi:i;  i;sori!.\(U-s.  and  tiiaciika.  14"J 

111  oporiitioiis  Tor  cancer  aiiywlici-c  il'  the  lield  is  imt  prolecteil  tlie 
entire  raw  snrl'aee  area  will  lie  miwh  with  cancer  I'clls  ami  a  rich 
i^rowth  (if  cancer  will  sjiriim  ii]i  over  the  eiitir<'  wdiukI  siirfaee.  will 
liidw  riiri.msly  and  iisnall>  will  cause  the  death  of  the  oatient  in  less 
time  than  'would  the  orijjinal  iirowth  had  it  been  left  unmolested. 
This  is  ])erhai)s  the  most  imiiortaiit  point  to  lie  considered  in  the 
treatment  of  eancer  of  tlie  pharynx,  tlie  tonsil,  the  pillars  or  the  riina 
iilottidis  The  oi)enitioii  is  teeluiieally  beset  with  diilicnlties  liut  no 
instrument,  no  linsi'er,  no  sponge,  that  has  toueheil  the  cancer  surface, 
should  be  used  aiiain.  nor  shdiild  the\-  touch  anvthiui;-  else  that  may 
be  used  ill  the  operation.  The  o|ieratioii  -^lnuild  iint  be  undertaken 
if  its  result  is  to  be  no  more  than  the  iinplaiilation  of  a  new  ciineer 
that  may  extend  e\cii  farther  than  the  orii-inal  growth.  The  only 
means  by  wliich  the  reiniplaiitation  of  cancer  cells  may  be  ])revented 
is  by  the  immediate  and  complete  destruction  of  the  oriuinal  fi:rowtli 
liy  thermo-cauterization.  Care  must  then  be  taken  to  jirevent  the 
dislodgment  of  the  eschar-  and  even  after  these  precautions  have 
been  taken  it  is  best  to  follow  the  operation  li\-  the  use  of  the  X-rav  if 
the  field  is  acces^ilile.  It  is  wise  also  to  iiiaki'  a  xciy  wide  excision 
of  the  ijrowth,  and  to  renioxc  .-ill  the  lymphatic  nodes  which  drain  the 
involved  area.  Jn  serious  risks  it  is  liest  to  perform  the  operation  in 
two  staires,  first  excisin,i>-  the  local  field,  and  then  after  ten  days  or  more 
removiuo-  the  lymjihatic  beariii,<>-  tissue  of  the  iiecdv  by  a  block  excision. 
If  the  growth  is  located  in  the  tonsil  or  tlie  ])illars  it  is  possibl(>  to  give 
the  anesthetic  and  to  )irevent  tlie  inhalation  of  lilndd  either  by  passing- 
tubes  through  the  pharxnx  and  packini:  them  with  gair/.e,  or  by  the 
intratracheal  insuffiation  method  df  M'ltzer  and  Auer.  If  the  cancer 
is  still  lower  down,  it  is  lle^t  td  iiiaki'  .1  preliminar\  trachcdtdmy  ami 
introduce  as  large  a  rublier  tube  as  the  ti'achea  will  lidld.  thus  pM'\-eiit- 
ing  the  inlialati<in  (<\'  iilodd.  In  dpei-ations  on  the  tonsil  the  ap]ilication 
of  a  Crile  clamp  cm  the  external  cardtid  arter>'  will  minimize  the 
hemdrrhauc. 

Excision  of  the  Tonsil  for  Cancer.  —I'earing  in  mind  the  gi'iieral 
precautions  stated  almxc.  the  excision  of  the  tonsils  for  cancer  is  ]ier- 
formed  in  the  followiim  manner: 

1.  A  tube  fdi-  the  administratidii  of  t  he  anesthetic  is  passed  through 
the  iiharynx  and  held  by  gauze  packing. 

12.  All  of  the  visible  growth  is  com|iletel\  <lestroyed  by  thi'rmo- 
canterizatiou. 

3.  The  lymphatic  glands  which  <lraiii  tiie  tonsil  are  excised  01  bloc 
through  a  wide  neck  incision. 

4.  The  external  carotid  is  ck)sed  by  means  of  the  (rile  (damp. 


150  OPEKATTYE   SUKGEKY   OF   THE   NOSE,   THROAT,   AND  EAR. 

5.   ir  more  room  is  needed  the  ramus  of  the  jaw  is  diYided. 

ti.  Willi  the  fingers  of  one  hand  inside  the  throat  a  \vide  dissection 
is  made  (if  the  base  of  the  gTO\Yth,  extreme  care  being-  taken  to  leaYo 
nudist uibcd  the  eschar  surface.  Internal  as  well  as  external  dissection 
sliduld  be  ust'd  if  necessary. 

7.  The  Ycssels  are  closed  carefully.  A  cuiYcd  needle  and  catgul 
iieiug  used  if  necessary  to  control  oozing-  in  the  mouth. 

8.  Tlie  clamp  is  remoYed  from  the  external  carotid. 

S).  A  Lane  plate  is  applied  to  the  divided  ramus.  The  plate  may 
cause  sui)puration,  but  it  will  hold  the  bone  in  i)lace  until  union  has 
been  secured. 

10.  The  womid  is  immediately  exi»osed  to  X-rays  if  the  iiatient's 
condition  warrants  it. 

n.  The  wound  is  packed  with  iodoform  gauze — the  external  wound 
being  pai'tially  closed. 

Cancer  of  the  Pillars — In  operations  lielow  the  tonsil  the  best 
procedure  is  to  ])erform  a  traclieotomy  and  then  to  open  the  pharynx 
freely  by  means  of  an  ample  incision  just  aliove  the  hyoid.  The  same 
procedures  as  those  described  in  the  operation  for  cancer  of  the  tonsil 
are  applicable  here  except  that  the  wound  in  the  neck,  by  means  of 
which  the  exposure  is  made,  is  closed  at  once,  and  it  is  not  necessary 
to  apply  temporary  clamps  upon  the  carotid.  It  is  well  to  allow  the 
tracheotomy  tube  to  remain  until  the  ]iharyngeal  w'ound  is  well  healed. 

Stenosis  of  the  Pharynx. — The  discouraging  results  of  operatiYe 
procedures  for  the  relief  of  stenosis  of  the  pharynx  are  well  illustrated 
by  the  following  history  of  one  of  the  author's  cases.  This  patient 
has  already  undergone  twenty-four  operations  of  various  kinds  in- 
cluding all  the  intrapharyngeal  methods.  The  author  i-esolYcd  to 
make  a  wide  excision  of  every  vestige  of  the  stricture.  A  preliminary 
tracheotomy  was  made,  ten  days  after  which  the  principal  operation 
was  performed.  An  incision  was  made  around  the  anterior  half  of 
the  neck  througli  the  skin,  platysma  and  fascia.  The  pharynx  was 
then  o])ened.  With  one  hand  inside  the  pharynx  the  dissection  above 
and  lielow  tiie  stricture  could  be  accurately  guided  so  easily  that  the 
author  was  able  to  make  an  annular  resection  including  the  entire  area 
of  the  scar.  By  means  of  a  long  needle  with  an  eye  near  the  point 
mattress  stitches  were  inserted  into  the  opposing  pharyngeal  walls, 
thus  bringing  together  this  enormous  opening  in  the  throat.  The 
wound  liealed  splendidly,  but  after  some  months  the  stricture  recuiTed. 

The  author  then  planned  another  type  of  operation.  A  long 
perineal  needle  with  an  eye  near  the  ])oint,  threaded  with  heavy  silver 
wire,  was  passed  throuiih  the  skin  of  the  side  of  the  neck  and  through 


i.Ar,\  \N.   i'iiAi:\\N.   ri'i'K.i;   i;sni'ii.\(;rs.   and  tkaciika. 


1.")] 


all  till'  soft  pai-ts  Wtiwu  t(i  tlic  l>;isr  <<(  ih,.  -irictiiiv.  'I'Ih'  Imsc  of  the 
ptricturo  was  tlu'ii  jiii'i-cccl,  llu'  nccdli'  imssini;-  iiitu  tlu'  nmiitli.  'I'lu' 
silvor  wii-t"  was  tlim  dclaclu'il  tVdiii  the  i'\r  and  llif  in'cdlr  was  with- 
drawn until  the  pnini  was  uncc  nun-c  external  tn  tiie  liase  n\'  tlic  stric- 
turo,  and  was  tlion  i)assod  tlifoiiiili  the  small  openini;-  in  the  center  of 
the  pharynx.  The  free  end  of  the  sihcr  was  attain  tlireaded  into  the 
eye  of  the  needle  anil  the  needle  was  withdrawn.  In  this  manner 
one  side  of  the  scar  was  ura.-iied  liy  Ihi'  huip  of  heavy  silver  wire. 
Another  wire  was  >iinilai-ly  inseited  intn  the  ii|iiiosite  side  and  l)o1h 
wires  were  tJLiiitly  twisted,  'i'lie  ]mi-|Hi-e  of  this  ]iroeedure  was  to 
foi-ni  a  iHueous  inenilirane-eo\-ered  iistnla  analou'ous  to  the  skin  listula 
one  makes  when  upei-atinL:'  for  wch  linL;'er.  This  was  i'aithrully  ti'ied 
hnt  nnfortunatel\-  the  wake  of  the  wire>  lilled  as  fast  as  they  cui  their 
way  out.  The  ant  hoi-  tiien  ahandoned  further  efforts  and  made  an 
(>sopha,ii:o?toniy,  which  appeared  to  he  the  only  possible  means  of  relief. 

Esophagostomy.  Like  tiacheutomy  and  enterostomy,  esopliasos- 
touiy  iHa>  he  |iennanent,  or  it  may  he  used  for  temporary  purposes 
only.  The  author  has  many  times  niaile  use  of  esopha^'ostomy  for  a 
temporary  ])urpose,  elosini;-  it  after  it  has  served  its  purpose.  The 
most  striking;-  case  of  this  nature  was  the  eas(>  of  extrinsic  laryngeal 
cancer  already  described  in  whi<'li  the  larynx,  the  liyoid,  a  large  por- 
tion of  the  pharynx,  the  tonsil>,  the  base  of  the  tongue  and  all  of  the 
intervening  tissue  were  excised.  .\(  the  end  of  the  operation  no 
pharyngeal  mucosa  was  left.  The  esophagus  was  stitched  up  into  the 
skin    at    the    side    of   the    neek    and    was    seeiindy    fastened    with    silk 

sutui'es.     The  traehea  was  stitehed  to  ti jiposite  side.     After  a  lime 

new  mucous  membrane  spread  o\cr  the  |iiiarynx.  The  author  then  in 
several  stages  freed  the  esojjhagus  from  its  attaehiiieiit  to  the  skin  at 
the  side  of  the  neck  and  brought  it  to  the  median  line.  In  two  more 
seances  he  sutured  the  larize  hiatus  in  the  anterior  pharynx.  After 
a  good  union  was  secured  the  e-ophagostomy  opening  was  linally 
closed.    The  jiatient  made  an  excellent  recovery. 

In  performing  an  esophagostomy  the  important  ]ioinl  is  to  make 
the  incision  so  ample  that  all  the  fiehl  may  he  >een  clearl>\  (fig.  110.) 
The  dissection  shoidd  he  so  controlled  that  tiie  recui-reiit  laryngeal 
nerve,  the  big  hloiul  vessels,  the  \a,i;iis  and  the  other  important  struc 
tures  may  all  be  so  clearly  seen  that  they  cannot  be  mistaken  mu-  in- 
jured. (Fiu-.  111.)  If  each  steji  in  the  operation-  howcxci-  minute- 
is  controlled  not  the  slightest  mishap  need  occur,  .\fter  the  esoi)hagus 
has  been  reachetl,  however,  it  is  important  tn  a\iiid  extending  the 
dissection  in  the  ne(d\  tiie  least  l)it  more  than  is  reijuired;  for,  in  the 


152 


(ii'ki;a-|'i\k  sri;iiKi;v  ok  tiif,  xosk.  tiiikiat.  axd  kak. 


lirst  iil;ifc,  :i  wide  disscctidii  is  iidl  needed:  and,  in  the  second  place, 
llu'  di'e|i  iilanes  of  tissue  ill  the  neck  JLave  linf  little  jiower  of  resisting 
infection. 

If  no  oineriicncy  exists,  it  is  even  safer  to  liriiig  tlic  esoitliagns 
well  np  into  the  wonnd;  to  jiass  a  small  strip  of  iodofoi-ni  gaiizo  around 


Fig.  110. 
Es()iilia)j;ostomy.      Ample   incision   of   sliiii   aldiiK  the   anterior   l)or<ler   of 
stei'iiomastoid  musi-le. 


it;  and  to  pack  tlie  wound  gently  for  several  days  before  the  esophagus 
is  opened.  This  point  is  not  of  sniiticient  importance,  however,  to  justify 
any  loss  of  time.  The  fixation  of  the  esophagus  to  the  skin  is  most 
safely  made  by  means  of  silk  interrupted  sutures.     (Fig.  112.) 

The  author  has  been  happily  surprised  to  obsei've  tlie  ease  with 
which  patients  swallow  even  when  the  esophagus  is  brought  to  the 
edge  of  the  skin  wound. 


i.Ai;\  x\.   ^ll.\l:^  NX,   ri'iM;i;   i:>(irii.\i;(s.  anh  TiiAciiKA.  IT)!) 


Cancer  of  the  Esophagus.  CaiKiT  of  tlir  esophagus  is  rarely 
ciu'cd  Tor  iiMially  the  ciuidit icui  i>  iint  ri'co.ii'iiizcd  until  symptoms  of 
olistruftiun  a|ipcai-.  li\  wliii'li  lime  tlie  disease  has  ahnost  certainly 
spread  into  inafcessihle  teriitorx. 

The  toclmie  of  i-eseclimi  nf  liie  e^iipliaiius  for  cancer  is  essen- 
tially the  same  as  that  alicadx  dex-iilied  W^y  esnpliaiiostomy.  The 
incision  should  he  ample  eiiniiL:li  tn  expose  the  eaiieer  l'oi-  a  considcr- 
alilo  distance  alui\e  and  helow  llie  liiint>  of  the  caiit'eroiis  tissue.  It 
is  rarely  pos>ilile  to  llinte  the  ends  of  the  divided  eS())iliaiillS. 

Diverticula  of  the  Esophagus.- opeiat ions  for  diverticida  of  the 


esophagus  jjresiMit  a  sharp  coiiti-ast  to  tiio>e  for  pharyiiu'eal  stricture, 
for  the  forniei-  ai-e  usually  successful.  Tin'  autlioi-  has  opei'aled  on 
five  oases  and  found  them  readily  cin-aMe. 

I'.efore  operation  X  ra\  hisuiuth  pictures  should  lie  made  to  de- 
termine the  exact  location,  the  extent  ami  the  nature  of  the  sac  which 
is  most  comuionlx  situated  at  the  upper  lateral  aspect  ol'  the  esojjha.ii'us. 
often  exteiidiuL;-  downward   helow  the  claxicie  e\-eu. 

The  o|iei-ation   i-  p<'rl'oi-med   in   the   folhiwini;'  mauiU'r: 

1.  .V  lon.u'  \-ertical  incision  is  made  ovt'i-  the  middle  of  the  sac. 

'2.  By  sharp  knife  dissection  the  sac  is  exposed,  the  field  being 
kept  liloodless  and  trair-luceut  li\-  pickim;-  up  and  clMmpiuL;  each  \-ess(d 
either  hefore  oi-  at  tlie  moment  of  its  division. 

'■'.  The  entire  poncdi  or  sac  is  i>olated  up  to  its  esojihaifcal  or 
lihar.vimeal  point  of  origin. 


i:.4 


(IPKIIATIVK    SriUlKltV    OK   TIIK    XO.SE,    TllKiiAT.    AMi    KAII. 


4.  'I'lie  siU"  is  cut  off  exactly  as  one  cuts  oil'  a  lu'inial  sac.  Tlio 
oi)eniii,ij:  of  the  diverticulum  is  closed  by  a  silk  siiture  preferably  willi 
a  (•(^lililci-  stildi.  Tlif  first  row  of  stitclios  is  roonfnrccd  1iy  a  second  row, 
and  a  small  drain  is  inserted  al  (he  lower  end  ol'  the  wnund  after  rlos- 
itii;'  the  o\ crlNin,';'  tissues. 

If  tile  diverticulum  he  hi^h  uji  on  the  eso]iha,iiUs,  especially  if  it 
involve  the  jiharynx,  the  )>atieut  should  not  he  allowed  to  swallow 
until  the  line  of  union  is  well  estahlishe(l.  As  the  victims  of  esophaueal 
diverticula     have    usuallv     had     mucli     experience     with     throat    ami 


Es(il)liafr')stniir 


Fig.  112. 

Esophagus  stitcliod  to  skin. 


esophageal  instrumentation,  the  insertion  of  a  small  flexible  tube 
through  which  nourishment  may  be  given  will  be  no  liardship. 

One  of  the  author's  iiatieuts  had  had  another  diverticulum  re- 
moved twelve  years  previously.  In  this  case  the  phar^aigeal  wall 
was  strikingly  thin,  and  in  addition  to  two  diverticula  the  pharynx 
was  greatly  dilated  on  the  same  side.  The  site  of  the  first  ojieration 
was  clearly  visil)le,  the  scar  being  sound.  Both  diverticula  were  re- 
moved and  in  addi1i<Mi  a  large  elliptical  portion  of  the  dilated  pharynx 
was  excised.    The  result  has  been  excellent. 

Diverticula  with  narrow  necks  are  of  course  the  easiest  to  remov^e. 


(11  \i'Ti:i{  w 

L\KVN(.()S( DIM ,    I K ACIIKdSCOn .   liKONCIIdSCOrV.   KSOI'll Al.USCon . 
AMI  (.ASIKOSCOI'V. 

I5y  Harris  1*.  MosIut.  .M.  D. 

THE  DIRECT  EXAMINATION  OF  THE  LARYNX 

Historical.  Kiislcin  in  l^'.t4  iiitioihicnl  tlio  diivct  iiu-tliod  of  ox- 
aiiiiuin.ii  the  laiynx.  The  iiisliuinnit  with  whicli  he  accomplished  tlio 
exposure  of  the  larynx  was  an  elongated  tongue  deiiressor  with  hoods 
of  varions  sizes.  Killian  took  nj)  the  procedure,  «nd  ehangfed  the  flat 
speculuui  of  Kirstein  into  one  of  tuhular  form,  systematized  the  steps 
of  the  examination  and  won  from  tlie  medical  profession  the  recogni- 
tion of  its  groat  value.  The  foresight  and  enthusiasm  of  Killian  have 
licen  supiilemented  by  the  great  inventive  ability  of  Briinings.  The 
result  of  the  la])ors  of  these  men  has  been  that  a  number  of  instruments 
are  available  today  for  the  direct  exniiiiii.il  ion  nf  tlie  larynx. 

The  arlvantages  of  the  direct  exaniiiialiun  of  the  larynx  are  self- 
evident.  It  is  the  natural  method.  The  phj^sician  works  upon  the 
larynx  in  the  same  fashion  tliat  a  suigeon  works  uiion  any  other  ])art 
of  the  body.  Manipuhitioiis  in  tiu'  hnynx  eairied  mit  uihlei-  tin'  guid- 
anee  of  a  niii'ror,  are  executed  niuuil  a  right  angle  eoi-ner  w  itii  the  ante- 
rior ami  I Kisterior  positions  nl'  tin-  \ariiin>  parts  of  tin-  larynx  reversed. 
The  indirect  method  of  examining  and  operating  \ipon  the  larynx  must 
lie  ci'edited  with  vei'v  great  accom]ilis]iinents,  and  it  will  always  be 
em])loye(l,  but  tin-  -p<'eial  workers  of  tin-  cuniing  uvniTat  ion  will  turn 
instinctively  to  dii'ect  manipulations  npim  the  larynx  latlur  than  to 
the  older  procedure. 

Contraindications.  Absolute  contiaindieations  to  the  employment 
of  (liiect  inspertiiin  (if  tile  larynx  are  seldom  found.  Chief  among 
these  is  a  high  grade  of  <lyspnea.  The  direct  examination  should  not 
be  attempted  in  severe  cases  of  uncompensated  heait   lesi(Uis,  or  in  a 

*Thts  article  is  based  upon  the  writings  of  Ilriinings.  Kahlcr  and  Jackson.  The  author's  own  ex. 
;>criencc  furnishes  a  certain  small  part.  ICpitomes  of  new  work,  and  sucii  in  great  measure  is  this  article, 
must  go  to  the  original  sources  for  the  facts.  This  the  author  has  <lonc.  He  wishes  here  to  make  full  and 
grateful  acknowledgment  of  his  indebtedness. 


^~^(\  (ti'KKATiN  r.  srniiEr.Y  of  the  xose,  TirnoAT,  axd  ear. 

case  n\'  ;h1\;iiicc(I  ;iiicuiisni.  Intractable  .i^'aj'-giu,";-  in  sjtitc  of  thoi-oiiiili 
cocainizatiiiu  i>  udt  sn  iinicli  a  routraindicatioii,  altlmnuh  the  result  is 
tlio  same,  as  it  is  an  insurmountable  obstacle.  Where  the  direct  ex- 
amination iiroves  to  l)e  impossible,  it  is  generally  due  tn  uncontrollable 
i-eflexes.  Howex'er,  unless  there  is  some  disease  of  tlie  crrvical  verte- 
bi'a'  or  some  unusual  mali)osition  or  deformity  of  the  larynx  the  direct 
examinatidu  is  almost  always  possilile  under  general  anestliesia. 
Where  the  ]iatient  is  suffering  from  marked  dys]inea  the  performance 
(if  tracheotduiy  usually  makes  the  direct  examinatidii  possible. 

Uncontrollable  gagging,  the  chief  difficulty  in  carrying  out  direct 
examination,  interferes  fully  as  much  in  the  indirect  method  as  it  does 
in  the  direct.  In  either  case  it  uuist  be  successfully  (■(lud)atted  before 
the  examiiuiti(Ui  can  proceed. 

The  Choice  of  the  Aesthetic. — In  I'xamining  the  larynx  directly 
the  operator  has  the  choice  of  local  or  general  anesthesia.  Some  form 
of  anesthesia  is  necessary  on  account  of  the  gagging  and  coughing  far 
more  than  on  account  of  the  ])ain,  since  the  manipulations  employed  in 
the  direct  examination  of  the  larynx  and  trachea  give  rise  to  but 
little  pain.  It  is  essenti^d,  therefore,  to  do  away  with  the  sensitiveness 
only  of  the  mucous  membrane.  This  can  be  brought  about  either  by 
the  use  of  coca  in  locally  or  by  the  production  of  general  anesthesia  in 
addition  to  local  anesthesia,  because  even  with  the  general  anesthesia, 
the  use  of  cocain  is  necessary.  The  operator  ought  not  be  a  partisan  in 
this  matter.  He  should  employ  either  form  of  anesthesia  at  will.  In- 
fants and  children  are  best  examined  under  general  anesthesia.  In 
many  adults  a  satisfactory  examination  is  possible  only  under  ether. 
Certain  systemic  diseases  like  multiple  sclerosis,  bulbar  paralysis,  tabes, 
and  hysteria,  increase  the  sensitiveness  of  the  mucous  membranes.  In 
old  subjects  the  mucous  membrane  of  the  larynx  and  trachea  is  often 
very  tolerant.  In  robuist  males  with  chronic  catan-h.  twice  or  three 
times  the  amoiuit  of  cocain  as  is  re(|uirtNl  foi-  women  is  often  needed  to 
produce  anesthesia. 

Cocainization. — Briinings  with  his  customary  thoroughness  has 
studied  the  iiietliods  of  cocainization  exhaustively.  He  has  demon- 
strated that  cocain  applied  by  a  brush  or  swab  is  three  times  as  effec- 
tive as  it  is  when  introduced  by  a  spray.  If  adrenaline  is  added  to  the 
cocain  solution  the  anesthesia  is  noticeably  prolonged.  Briinings  uses 
a  syringe  which  he  converts  into  a  swab  syringe  by  winding  cotton  on 
the  tip  of  the  canula.  The  barrel  of  the  syringe  is  graduated  so  that 
the  operator  can  control  the  dosage  of  cocain.  This  author  finds  that 
on  the  average  five  drops  of  a  twenty  per  cent  solution  is  sufficient  to 
produce  anestliesia  in  an  adult.     In  children  the  strength  of  the  solu- 


T.Ai;Y\(ins(^orv,  r.i;oxci!()scor>'.  F.sopiiAcoscorY,  ktc.  1;)7 

tion  is  reduced  Id  ten   piT  i-ml.  Iirc-ni-c  IIm'V  dn  im)    lolrr.-ili'  llic  dnii; 
as  well  as  adults. 

AVilli  a  >\vali  or  llic  >\\  ali  >>  i-in-v,  a  drop  of  ;i  1  unilx  \iit  cent  -ohi 
lion  of  cocain  is  aii|>lied  to  the  lia>e  of  the  toiiuuc.  .-md  another  to  the 
poslei'ior  jiharynaeal  wall.  Aftei-  ;iii  inteixal  ol'  tlu'ee  or  I'our  minutes 
the  cocain  i>  aiijiiicil  to  the  ti]i  of  the  epiulottis.  (•'inaliy  a  dro|i  oi-  two 
i.-  placed  ill  the  larvnx.  Thi^  call>  for  accurate  do<a,ue.  Tln'  writer  of 
tlii-  article  ha.-  not  had  any  e\perieiice  with  the  liri'.-h  or  .-wali  >yrin,ae. 
hut  lia.s  used  the  simple  >wah  and  with  it  a  ten  per  cent  soluti.ui  of 
(.'ocaiu  for  the  lirst  of  the  aiiest  lie>i;i.  and  a  twenty  per  cent  -olutiou 
ill  tic  laiyiiN.  The  weaker  solulion  allow-  the  cocain  to  he  employed 
more  freely.  I'ntil  the  liei^inner  perfects  hi-  technic  he  will  do  well  to 
use  the  weaker  soluliou  for  the  mo-t  |)art.  If  cocain  is  mixeil  with 
adrenalin  chloride  much  stron,j;-er  solulions  can  he  u-ed  iii  the  larynx. 
Some  operators  eini)loy  as  hii>li  as  fifty  ])er  cent. 

The  Difficulties  of  the  Examination. — 'I'he  i>reatest  diOienlty  in  the 
way  of  a  siiceessfnl  exainiiiation  is  iiic(uiiiilete  aiu'sthesia.  ^Pinie  is  lost 
and  the  examination  is  rendered  inconiplete  or  made  inipos-ilile  unless 
the  anesthesia  is  profound.  Fr(Hii  its  nature  the  i)roeedure  of  direct 
examination  is  disconcert inji-  if  not  alarinin;;-  to  an  inexiierieiiced  pa- 
tient. Therefore,  the  patient  should  he  calmed  l>y  the  assurance, 
repeated  if  necessary,  that  he  will  not  straniile.  lie  is  encouraged  to 
hold  tlie  head  as  loosely  as  he  can  and  to  hreatlie  i|uietl>  and  re,i;-u- 
larly.  From  time  to  time  the  exainiiiation  is  interniiited  in  order  that 
the  patient  may  sjiii  out  the  accannnlated  saliva,  lie  is  cautituied  to 
do  this  quietly  and  not  to  hawk.  Durinii-  the  examination  the  patient 
is  lialile  not  only  to  heiid  the  head  loo  far  hack  hut  to  allow  the 
whole  hody  fr(uii  the  knees  up  to  swin.i;-  hackward.  The  assistant 
should  see  to  it  that  the  jiatieiit  keeps  strai,<>iit  ami  erect.  These 
are  the  principal  ami  natural  faults  into  which  the  patient  falls.  The 
faults  of  technic  to  which  the  examiner  is  liahle  are  also  natural  ones. 
The  first,  incomplete  cocainization,  is  due  to  haste.  For  the  patient's 
sake  he  wishes  to  y'et  the  examination  over  (piickly.  The  second  mis- 
take on  the  iiart  of  tlie  ])hysician  is  to  insert  the  siiecnlnm  too  deeiily 
at  first  and  in  conse(|uencc  to  miss  and  to  jiass  the  epiglottis  and  to 
strike  the  point  of  the  instrument  anain-t  the  posti'rior  pharynu'eal 
wall.  This  produces  nncoiit  rollahle  naiiiiimz'  ami  oflen,  for  the  da\  at 
least,  makes  further  uianipulation  impossihle.  In  pressiiu;-  tin'  epi 
glottis  and  the  hase  of  the  tonmie  forward  the  specnlum  slnuild  he  held 
firmly  and  the  procedure  executed  in  a  deliheiale  ami  nnhesitatin.a,- 
fashion.  Otherwise  the  tonp^ie  is  tickled  and  rehels.  I'nder  lirni  pres- 
sure it  yields  and  suhmits.     AVlien   the   tip  of  the   s)ieculinii   has   en- 


\'^^  (irKMATIVE   SnUiEKY    OK   THE    XOSE,    THIIOAT,    AX1>    EAR. 

torcd  the  lar\mx  there  is  daiiiior  of  the  sliaft  striking'  a.^-ainst  the  teetli 
or  the  unprotected  gums,  thus  causing  pain.  The  examiner's  finger 
should  be  so  placed  as  to  prevent  tliis.  Tin-  success  of  the  examina- 
tion depends  most  of  all  upon  the  eliaracter  of  the  patient's  neck.  If 
he  has  a  thin  neck,  and  if  he  is  fortunate  enougli  to  have  no  teeth  the 
prospects  of  a  successful  examination  are  good.  If,  on  the  contrary, 
the  patient  has  a  short,  thick  neck,  and  a  protruding  ui)i»or  jaw  and 
retains  all  his  teeth,  the  outlook  for  the  examination  is  not  so  liopeful. 
The  amount  of  force  required  to  bring  the  lar^nix  into  view  varies 
with  the  individual  neck.  Briinings  has  made  the  observation  that  a 
force  of  10  kg.  is  bearable,  15  kg.  painful,  and  20  kg.  unbearable. 
He  has  found  also  that  the  ease  of  seeing  the  anterior  commissure 
varies  greatly;  in  fact  it  may  be  thirty  times  as  difficult  in  one  pa- 
tient as  in  another.  The  harder  it  is  to  obtain  a  view  of  the  anterior 
commissure  the  smaller  must  be  the  diameter  of  the  speculum.  With 
a  speculum  of  9  mm.  diameter  a  pressure  of  9  kg.  will  expose  the 
anterior  commissure.  With  a  speculum  of  14  mm.  diameter  the  same 
amount  of  force  will  expose  only  the  posterior  part  of  "the  lar\Tix. 

The  Method  of  Making-  the  Direct  Examination. 

The  patient  should  be  examined  if  possible  when  the  stomach  is 
empty.  If  the  physician  feels  that  his  patient  will  be  unruly  a  dose 
of  bromid  or  morpbin  some  little  time  before  is  of  benefit.  The  patient 
is  seated  upon  a  low  stool  (30  cm.  in  height),  and  the  assistant  stands 
behind  and  supports  the  head.  The  patient's  head  is  bent  slightly 
backward. 

The  patient  protrudes  his  tongue  and  holds  it  witli  liis  left  liand. 
The  examiner  guards  the  upper  teeth  of  the  patient  with  tlie  forefinger 
of  his  left  hand  at  the  same  time  pushing  the  upper  lip  out  of  the 
way.  The  thumb  of  the  left  hand  is  held  against  the  left  forefinger  and 
the  angle  between  the  two  fingers  is  made  to  serve  as  a  guide  for  the 
shaft  of  the  speculum.  Two  forms  of  specula  are  used  for  direct  exam 
ination,  the  tubular  speculum  of  Jackson  (Figs.  113  and  114)  and  the 
speculum  of  Briinings.  Su])pose  that  the  instrument  of  .Jackson  is  the 
one  wliich  the  examiner  is  usiiic'.  It  is  maiiipuUited  as  follows:  Tlie 
blade  of  the  speculum  is  carried  into  the  mouth  along  the  central  line 
of  the  tongue  until  the  tip  of  the  epiglottis  appears.  As  soon  as  this 
is  recognized  the  end  of  the  speculum  is  carried  over  it  This  is  the 
first  stage  of  the  examination,  if  for  purposes  of  clcainess  the  exam- 
ination is  described  in  stages.  It  is  vital  for  the  success  of  tlie  ex- 
amination not  to  have  this  first  manipulation  miscarry.  Wlieii  tlie 
epiglottis  has  l)een  passed  by  the  tip  of  the  S]i('cuhnii,  the  luuidlc  of 


i.Ain  X(;()sn(r\,   iiiioMiKisroPV,  icsni'iiAcuscopv,  ktc. 


]:>'.) 


(lie  iii^truiuciit  is  iiciilly  laiscd  and  at  tlio  same  liiiii'  llic  |)alii'iit's  licati 
is  allowed  to  swiim-  l)aci<\vaid  slightly  and  Ity  dcf^Tocs.  As  tlic  licad  of 
the  patient  uucs  hack  the  (MkI  of  the  siieciiinni  is  puslied  (htwnwaid 
aloii,2:  the  posterior  surface  of  the  epif^lottis  into  the  vestibule  of  the 
larynx.  From  the  moment  that  the  tij)  of  the  ejti^lottis  has  l)een  ])assed 
until  a  satisfactory  view  of  the  larynx  is  ohtained,  firm  pressure  is  ke])t 
upon  tlie  Itase  of  tlie  toii.nue  liy  lifting-  u])  the  handle  of  the  s])eculuni  and 
lliiis  forcinu-  its  sliaft  and  tip  forward.  The  discovery  and  tlie  passing;' 
of  the  tip  of  the  epiglottis  constitute  the  first  sta,2;e  of  the  examination, 
the  sinkini;  of  the  speculum  into  the  vestibule  of  the  larynx  the  second, 
and  the  ]nishinu-  of  the  e]ii glottis  and  the  base  of  tlie  tongue  forward. 


Fig.  113. 
.Jacksim's  tubular  speculum.     Tlic  instrument  is  made  in  two  sizes,  for 
eliUdren   and  adults.     Johnson   has  moditiod   this   speculum   In-  making   the 
horizontal  part  of  the  handle  detachable. 


till'  thiid  >tage.  If  at  aii\'  lime  the  exaiiiinei-  loses  his  way,  that  is, 
misses  the  e])i<!,lottis.  oi-  ^trikc^  the  p(i>1cri<ir  pliaryngeal  wall  or  fiiuls 
himself  in  the  pyrifonn  >imi>,  the  >pcculuiii  should  he  withdrawn  and 
the  examination  starteil  again  from  the  heginning.  It  is  a  help,  after 
the  tip  of  the  e])iglottis  has  been  ])assed  and  the  speculum  is  about  to 
enter  the  \c.-1ibnle  <>\'  the  hir>ii\.  to  ask  llie  palieiit  to  speak,  in  ordei" 
that  the  iiHAciiiciit  of  the  arytenoid  eartiUiges  may  give  the  ])ropi'r 
direction  for  the  (lee|ier  introtluction.  .\  successful  examination  should 
be  a  matter  of  only  a  few  minutes. 

Passing  the  Speculum  from  the  Comer  of  the  Mouth. —  If  there 
hapjM'Us  to  be  a  sufficient  gaj)  between  the  teeth  on  either  side  of  the 
u]i])er  jaw  advantage  may  be  taken  of  tliis  .space  to  pass  the  .speculum 


160 


OPEKATIX'!'".    srndKlIY    OK   THE    XOSK,    THIiOAT,    AXD    EAR. 


at  this  placi'.  If  no  ,t;a|i  exists  and  tlic  incisor  Icctli  afc  prominent,  tlie 
s|)ernhnn  ina\  Ite  jiassi'd  lietween  the  liicn^pitl  teetli  or  from  tiie  coi-ner 
of  the  mouth.  'I'he  distanees  are  shorter  and  the  miiseh's  more  rehixed. 
l''or  this  jairpose  tl:e  head  of  tlie  ])atient  is  I'otateil  a  litth'  and  heiit 
sliiihtly  to  the  opposite  si(U'.  Carried  out  with  a  sniad  Jackson  spec- 
ulum this  metliod  of  making-  the  direct  examination  is  very  successful 
in  children  and  infants.  This  ])rocedure  has  heen  especially  dexclopetl 
l)y  .lohuston. 

The  Direct  Examination  With  Counter  Pressure. —  In  the  direct 
examination  it  is  the  forward  pressure  of  the  si)eculuui  -which  enahles 
the  operator  to  see  the  larynx,  hut  this  at  the  same  time  limits  his  view 
hecause  the  laryux  as  a  whole  is  dislocated  consideral>ly  foi-\vard.     Tn 


Fig.  lu. 
Didgraiumatie  vopieseiitatiou  of  diicct  laryngoscopy  and  schema,  show- 
ing direction  of  force  applied  in  using  the  tulailar  speculum.     (After  Jack- 
son.) 


oi'der  to  counteract  tJiis  the  operator  almost  iustiiu'tively  ])uts  his 
fins'er  on  the  larynx  from  the  outside  and  pushes  it  hackward.  Briin- 
iiifi's  has  o'iven  this  common  manipulation  a  special  name,  direct  exam- 
ination with  coiniter-pi'essure,  and  has  devised  an  insti-umeut  to  do 
the  work  of  the  physician's  hand,  and  so  free  it  for  other  uses.  With 
this  instrument  the  inventor  states  that  the  antei-ior  commissui'e  can 
he  seen  in  all  cases. 

The  Direct  Examination  Under  Ether. — The  ]iatient  is  ])re])aied 
for  general  anesthesia  in  tlie  usual  way.  Before  he  comes  to  the  exam- 
ining tahle  h(>  is  giA'en,  if  an  adult,  a  sixth  of  a  grain  of  mori)hin  and 
one  one-hundred  and  fiftieth  of  a  grain  of  atropiu.  The  patient  is 
placed  on  his  hack  on  a  tahle  high  enough  to  ))ring  the  head  to  the 
same  level  as  the  face  of  the  examiner  if  he  i)refers  to  work  sitting.  If 
he  in-efers  to  work  standing  the  tahle  is  ]iut  ni)on  a  i)latform.     The 


l..\l;^■^"(;os^■^l■^ .   r.iidXciKiscdiM  .   I'.soniAiinscdiM'.  K'i'c 


Kil 


■■nitluir  lias  Inuinl  il  Ir^s  lii-iii-  and  Ic-s  a\\l<\\anl  \i>  iiial<i'  the  exainiiia- 
lidii  staiulin.u-.  ( Fiiis.  1 1.")  ami  I1fi.)  The  lu^ad  ami  >lit)ul(lors  of  the  pa- 
tient are  linmulit  over  tlir  mil  nf  the  laMf  wliili'  an  assistant  supports 
the  head  with  his  left  hand  n|"in  his  left  knrc.  The  knee  of  the  assist- 
ant is  sujjportod  at  the  proper  Inniiht  hy  an  ad, instable  foot  rest.  WIumi 
the  ether  has  been  well  stalled  the  phvsii'ian  eneaini/.es  the  deeji  pluw- 
ynx  of  the  jiatii'nt  and  the  region  of  the  pyril'onn  sinnscs  with  a  swab 


Fij,'.  llo. 
Position  of  second  assistf.nt  and  I'utient  for  endoscopy  per  os.     Gowns, 
paps  and  covers  are  omitted  to  show  (lie  |iositi(iii  liotlrr.     (After  Jackson.) 


saturatetl  with  a  ten  jier  cent  eocain  solnlimi.  Often  it  is  a  help  to 
have  a  suture  throu.yh  the  ton.uiie.  The  introdnction  of  the  spec- 
uhim  is  the  same  as  under  local  anesthesia  exeeiit,  of  course,  that  in 
the  majority  of  cases  it  is  easier.  The  ether  examination  is  resorted 
to  when  the  patient  is  inti'aetahle  nndev  local  anesthesia.  It  is  used 
in  the  case  of  children,  or  when.  lM>>ides  makini;  an  examination,  oper- 
ations of  consideral)le  extent  are  to  he  canied  ont.  The  assistant 
should  so  hold   the  head   of  the   iiatieiit    that    he  can   at    anv   moment 


k; 


OI'KIIA'I'IVK    sniCF.r.V    ok    the    XdSK,     lllllllA'l'.    AXII    KAi:. 


traiisl'cr  it  to  the  lininl  oi"  the  pliysieiau.  Ol'toii  tlio  physician  can  obtain 
a  Itcttcr  vifw  l>y  iiiaiiii)ulating  the  position  of  the  head  for  hinisclf. 
In  a  hard  examination  tlie  liead  passes  many  times  from  the  hand  of 
the  assistant  to  tlie  iiand  of  the  examiner.  The  assistant's  free  hand 
is  ready  at  an>   ninnu'iil  to  push  the  biryux  Itack  and  to  nianii)nhite  the 


Fig.  116. 
Bronc1uisco|iy  khuii  ;it.  Massachusetts  Greneral  Hospital.  The  elevated 
platform  is  shown,  with  the  operating  table  and  the  assistant  who  holds  the 
patient's  head.  The  iheostat  and  dry  cell  battery  are  seen  on  the  wall  at  the 
left.  Behind  the  assistant  is  a  Coakley  lamp.  On  the  left  also,  but  not 
slioBTi  in  the  photograph,  are  the  electric  suction  pump  and  the  ground 
glass  box  for  holding  X-ray  plates. 


anterior  commissure  into  view,  or  to  close  the  cords  in  order  to  show 
the  presence  of  a  new  growtli. 

In  examining  children  under  ethei-  it  is  not  always  necessary  to 
bring  the  head  over  the  end  of  the  talile.  If  the  occiput  is  allowed  to 
rest  on  the  tal)]('  and  the  cliin  is  brought  up,  in  very  many  instances  a 
Iterfect  view  can  be  obtained.    It  is  well  to  try  this  ])osition  first.    Often 


I..\RVXliO.St'i'l'>  .    l!l;n\(l|n<(n|>\  ,    KSOl'l  I  AtJUSCUPV,    liTC. 


lliis  ))()siti»ni  is  suctH'ssrul  also  willi  ailulls.  If  it 
(Iocs  not  succoL'd  the  lioad  may  ln'  tuinril  to  tlic 
sidi'  and  the  spoculimi  carried  down  lictwccii 
llic  l)iciisi>id  tooth  or  Troiii  tlu'  coiiit-r  of  tlic 
iiioiilli.  This  maiii|iiilatioii  is  csprciaily  iisci'ul 
I'or  introduciii.i;'  the  hroiiclioscopo  hotwocu  the 
cords  liccauso  it  is  easier  to  jict  in  line  with  the 
trachea  in  this  way  tlian  it  is  TroMi  tlie  niidide 
line. 

For  operatini;'  pnrjioses  Briininys  enijdoys  an 
Often  s]iecnlnni.  Some  years  i\v:o  the  author  de- 
vised practically  the  same  kind  of  a  speculum, 
and  used  it  for  some  time  but  soon  replaced  it 
hy  an  open  adjustable  speculum  of  the  pattern 
shown  in  Fi<i,-s.  117  and  118.  An  open  speculum 
increases  the  operating  field.    Such  a  speculum 


rig.  117. 

Xliislier's  !iiljii.st:il)li'  specuhim  for  direct   and  siispeiisiou  !anii;,'(isco|v 
(Side  vie»v.) 


IG-t 


HI'Kl-.ATIYE    SUKGEHY    OF   THE    ^lOSE,    TlinOAT,    AXIl    KAH. 


Fi-.   118. 

Moshei's  adjustable  specu- 
lum, showing  the  nipchanism 
liy  wliieh  the  speculum  can  Ije 
adjusted  to  any  width. 


is  the  (iiily  |);it(t'ni  tlii'Dimli  wliicli  dircci  iii- 
tnlnitioii  -with  the  larger  luln's  can  hr  jxt- 
I'onnc'd.  Tlic  eye  strain  in  iisiiiii'  tlic  open 
s])('culiiiii  is  Icssciu'il.  All  (he  landiiiaiks  of 
tile  ]iliaryii\  and  larxiix  are  visi))le  at  (iiiee 
aiul  in  their  natui'ai  ])ersi)ccli\('.  Tlu'  writer 
is  very  partial  to  the  open  specninni  wIh'ii  it 
ean  be  employed.  In  eliildreu  it  is  especially 
suecessful.  In  a]ipropriate  necks  of  adults 
it  is  also  successful.  The  author  always  tries 
this  form  of  speculum  first  liecause  Avhen  it 
succeeds  no  other  speculum  gives  as  ,<;-ood  a 
view.  The  open  speculum  may  he  used  Avith 
or  without  general  anesthesia.  However, 
with  infants  and  young-  children  for  obtain- 
ing a  diagnostic  A'iew  of  tlie  larynx,  for  in- 
tubation, for  extubation,  or  for  removing 
coins  from  the  upper  part  of  the  esophagus 
it  can  lie  employed  without  ether. 

The  Instruments  for  Direct  Examina- 
tion and  Direct  Operating. — Tlie  examining 
instruments  are  the  tubular  speculum  of 
Jackson,  the  speculum  of  Briinings  lighted  by 
the  electroscope,  and  fitted  with  the  attach- 
ment for  counter-pressure,  and  some  form  of 
open  speculum.  The  light  for  the  open  spec- 
ulum may  be  ol^tained  l)y  Jackson's  method, 
or  by  reflection  I'l'om  a  head  mirror.  The  in- 
struments used  through  the  various  specula 
in  direct  operating  upon  the  lary'ux  are  made 
with  the  shaft  of  the  proper  length  and  at  an 
a])propriate  angle  with  the  handle.  The  first 
instrument  is  the  laryngeal  knife.  The  other 
instruments  come  under  the  head  of  punches 
or  grasping  forceps.  (Fig.  119.)  The  shaft 
of  the  instruments  should  be  as  thin  as  pos- 
sible and  retain  its  rigidity.  The  instruments 
of  Briinings  are  most  excellent.  In  using  in- 
struments which  Avork  with  a  scissor  motion 
it  is  hard  to  judge  Avhen  they  are  placed  at 
the  proper  depth.  They  either  fall  short  or 
overreach    the    growth   to   lie   seized.     It   is 


i..\i;vxi;t\-^i(ipv.  MKtixt'iioscoi'v.  losoniACdscdi'V.  v.rc.  I'i' 

cMsii'i-  to  atl.jusl  ;ic<-iir;itcl.\  ;iii  iiist  luiiifiil  llir  lilmli's  nf  wliidi  .in' 
l)laco«!  at  ri-lit  aiii;lfs  t<>  tlic  end  d'  the  sliall  ami  whidi  rli.sr  u|inii 
cacli  (ttlicr   froiii  almxi'  dow  iiw  ai<l.     Tlir   lnw.i-   hladc   can    lie  canii'il 

hi'low  llu'  uTowtli  ami  llifii  lirmi-lit  ii|i\\aril  until  tlic  iiiii\i' nt   nf  tlio 

growili  sliows  thai  llir  lihuk-  is  Idiwliiui;-  il  \'yi>\\\  hrlnw.  If  \\\<'  liLnlcs 
ar(>  tlu'ii  sluit  tlic  l)it('  is  usually  succi'ssrul. 

In  lianl  oxauiinalions  wlioro  noitlici-  tin-  iiosilimi  of  llic  licad  uor 
(•iiunttT-prossurr  will  caiisc  the  s]i('ruliiiii  tu  IniiiL;  almiit  a  sullicii-nt 
view  of  tlio  larynx,  and  tlic  writer  nni>t  cdidV-s  that  lir  lias  had  such 
cases,  a  small,  short  iironelKiscoin'  iiitnidurrd  Ironi  tiic  anf?le  of  the 
mouth  will  at  times  hring'  into  view  the  desired  ]>art  of  the  larynx. 
The  writer  well  remembers  a  youuii'  sailor  of  sphMidid  jiliysique  who 
had  a  small  fibroma  situated  well  forward  mi  tlir  lil't  vocal  cord. 
Under  ether  a  most  tryinif  and  humiliatin.n'  oxaniination  followed. 
Success,  however,  followed  when  a  small  hroncluiscope  was  introduced 
from  the  an,yle  of  the  mouth  on  the  riiiht  and  caniid  into  and  across  the 
larynx  until  the  urowtli  was  pinned  inside  the  tiilic  and  a.i^ainst  the 
lateral  wall  of  the  larynx.  An  a>sistant  nicaiiw  liilc  pressed  the  larynx 
backward  and  made  counter-iu-essure  dh  tlie  left. 

A  wdrkinii:  set  of  instruments  for  linnielinscoiiy  is  as  follows: 

1.  .Tackson's   tubular  speculum    (adult  and   child   size). 

-.  -larksou's  lirouelioscopes  (7,  S.o,  10,  and  12  mm.  in  diamotpi). 

u.  Biuning.'i'  universal  electroscope. 

4.  Briinings'  extension   double  tubes   (7,  S..5,   10,    ti;.  auil    II    niiii.   in   diameter). 

il.  Briinings'  autoscope  or  sjdit  spatula  speculum   (11  and   li!  nun.  in  diameter). 

(i.  Briinings'  extension  forceps  witli   five   dilTcrent   tips;   or  .Tackson    forceps   with 

tips;  or  Coolidge  forceps  witli  .sliaft  of  tliree  lengths  and  tips. 

7.  Suction     apparatus     (hand    bulb,    hand    or    electric    aspirator,    with     three    tubes 

2.5,   35,  and   50   cm.   in   length). 

N.  Foreign  body   hook, 

il.  Casselberry 's  pin  cutter;  or  Mosher's  jiin  bender. 

10.  Briinings'    or    llosher's   safety   pin    closer. 

11.  .Jackson's  dilator   for  the  bronchi. 

12.  Mosher's    adjustable    speculum. 

l.'i.  Two   angular   locking  forceps,   for   use   with   the  open    speculum    (MosherV 

H.  Twelve  Coolidge's  cotton  carriers. 

I.'i.  Kirstein  "s  head   light. 

Hi.  Angular  laryngeal   knife. 

17.  King   punch,   for   work   about    the   mouth    of   the   esophagus   (Mosher). 

Tiiis  list  includes  instruments  for  obtainiufi:  li,<!;ht  in  tliree  dilVer- 
I'lit  wa>s.  The  head  minnr  juid  a  stamlini;'  electric  lamp  I'uniish  a 
r<iurtii.  The  latter  is  an  easy  method  of  obtainiiifi-  illnmination  for  the 
larynx  and  the  mouth  of  the  eso)iha,i;us.  It  is  economy  to  have  all  four 
in  the  ojjoratiujj;  room.  The  writer  has  his  examinin.a;  taltle  in  a  s|)ecial 
room  which  is  given  up  to  bronchoscopy  and  eso|iha.i;(isco|)y.    The  table 


1GG 


OPERATIVE   SURGERY   OF   THE   NOSE,   THROAT,   AXD   EAR. 


(Fig.  110)  stands  on  a  })latform  the  left  corner  of  wliicli  is  cut  out  to 
allow  standing  room  for  the  operator.  On  this  platform  beside  the 
examining  table  there  is  room  for  the  etherizer  and  tlie  assistant  who 
holds  tlie  head  of  the  patient.  On  the  right  oil  a  wall  bracket  is  a 
(\iaklcy  rheostat.  Below  this  is  another  shelf  for  the  Jackson  donlih' 
diy  cell  battery,  and  on  the  platform  is  an  electric  light  on  an  upright 
stand.  On  the  right  also  is  placed  an  electric  aspirating  pump.  Each 
piece  of  apparatus  is  connected  with  its  own  socket.  A  Kirstein  head 
light  is  kept  at  hand.  In  the  complete  operating  room  there  should 
be  an  illuminated  box  with  a  groimd  glass  face  for  holding  and  dem- 
onstrating X-ray  plates. 

The  table  for  instmments  is  placed  behind  and  to  the  right  of  the 
operator.  Beside  the  table  and  behind  and  on  the  right  stands  the 
first  assistant.    Opposite  the  first  assistant  Imt  on  the  other  side  of  tlie 


Fig.  119. 
Forcejis    for    direi-t    work    upon    the    larynx.       (Pfau.)       Various    tips 
(natural  size)  are  shown  below  the  forceps. 


table  is  the  nurse.  It  is  the  duty  of  the  nurse  to  load  the  cotti)n  car- 
riers. She  should  see  to  it  that  a  good  number  of  these  are  always 
ready  so  that  the  operator  may  never  liave  to  wait.  The  swabs  are 
loaded  either  with  cotton  or  better  with  small  pieces  of  selvedged 
gauze  cut  and  folded  to  the  proper  size.  It  is  of  the  utmost  importance 
that  the  nurse  and  the  first  assistant  should  knoAv  how  to  fasten  the 
swabs  securely  to  the  carriers.  When  the  operator  is  looking  down  a 
tube  he  should  not  be  required  to  turn  his  head  in  order  to  receive  an 
iiistrumeut.  When  he  asks  for  one  the  first  assistant  not  only  passes 
it  to  him  ovei-  his  shoulder  but  places  the  end  of  the  insti-ument  in 
the  mouth  of  tlie  tulie  and  its  liaiuUe  in  the  liaml  of  the  (i]iei-atoi-. 

Before  beginning  the  examination  all  instruments  should  be  tested 
and  proved  to  be  in  working  order.  Extra  lights  should  be  on  hand; 
or  what  is  better,  if  the  Jackson  bronchoscope  is  used,  an  extra  light 


LAUYXCDscorv.  itnoNciinsciipv,  icsoiMi.Mioscorv.  v:vr.  Itn 

carrier  with  a  ti'stotl  liulit  sIkhiM  Kr  in  rcailiin'ss.  Tiic  assistants 
should  know  how  to  rhnimr  tin'  liuhls  and  h<iw  to  adjust  tlio  instru- 
ments. 

I'vwi'v  detail  sliould  l.c  iir(>\  ideil  I'nr  hel'oro  the  examination  is  bc- 
.unn.  The  operatcu-  must  lie  willing  t<i  suiiei-vise  the  smallest  details 
if  he  wishes  the  exaniinalinu  tn  uo  (|uiikl>  and  smoothly.  The  suc- 
cess of  the  ojjeration  often  di'iK'uds  nimn  tlic  t  horouiihiiess  of  the  prej)- 
aration. 

On  an  aceessoi-v  taliK'  the  instruments  for  tracheotomy  should  be 
sterilized  and  ready  I'nr  use.  There  should  he  enouiih  assistants  for 
eai-ryiuii'  out  this  procedure  and  llu'y  should  lie  surgically  trained. 

The  Inhalation  of  Oxygen.— A  cylinder  of  o.\y,i;-en  ,u:as  should  lie 
in  every  operating;'  room  for  use  in  cases  calliut;-  for  lirouchoscojiy.  The 
administration  of  the  uas  nia>  make  i1  po^^il)lc  to  avoid  a  trache- 
otomy il  >c\-('|-c  dyspnea  is  present,  whih'  the  usi'  of  the  ;jas  to  comliat 
shock  and  respiratory  arrest  is  important.  If  a  i)ronchoseoi)e  is  in 
place  when  the  emergency  arises  the  gas  nia\  lie  administered  through 
this  directly,  or  through  the  suction  tube  if  the  .Jackson  type  of  bron- 
cho.scope  is  employed.  Daeger  has  devised  an  ajijiaratus  by  which  the 
amount  of  oxygen  aihninistei-ed  c,-in  be  accurately  nu'asured  and  con- 
trolled. 

Suspension  LarjTigoscopy. 

About  three  years  ago  Killian  introduced  sus])euslon  laryngos- 
copy. Within  the  last  twelve  innntli-  his  perfected  instruments  have 
begun  to  be  used  extensixcly.  The  underlying  princi]ile  of  the  pro- 
cedure is  the  transference  nf  the  weight  of  the  patient's  head  from  the 
band  of  the  cx.-unincr  tn  tiie  handle  i\\'  the  specninni.  This  gives  the 
physician  a  new  linriil,  his  left,  with  wliicli  to  work.  The  sns))ension  is 
accom]>lished  Ky  ehmgating  tln'  handle  (if  the  s|iecnlnni,  and  ending 
it  in  a  hook.  To  tlii>  handle  is  nttaclied  a  skeleton  inonthgag.  A  nut 
and  a  screw  in  the  handle  of  the  speculum  control  the  width  of  this. 
A  second  nut  and  screw  elevate  the  tij)  of  the  specninni.  Spatula?  of 
different  sizes  are  fitted  njjon  the  handle.  I'lacli  of  these  has  incor])o- 
rated  in  it  a  narrow  secondaiy  sjiatuhi.  The  position  of  the  tip  of  this 
is  again  regulated  by  a  nut  and  screw,  'i'he  .-iiiiiaint  us  is  ellieient  and 
beautiful,  but  coniplic.-ited.  The  elnini  1>  niadi'  for  it  that  besides  hold- 
jng  the  ]iatient's  head  it  will  al\\a>>  hiing  the  anterior  connnissui'e 
of  the  larynx  into  view.  'I'he  writer's  experience  with  the  apparatus 
as  yet  is  too  limited  to  pass  on  such  a  slateini'iit.  Init  from  what  hi' 
saw  at  Killian's  demonsti-ation  in  London  in  IIM."..  and  from  what  he 
has  learned  fi-om  the  nu'u  in  this  country  who  have  employed  the 
method  and  Killian's  instruments  extensiveix .  lu'  considers  this  state- 


168 


OPERATIVE    SI'IUiEKY    OF   THE    XdSE,    THROAT,    AND    EAl! 


nioiit  mueli  too  liroad.  Tliis  is  relatively  a  small  matter,  of  course,  be- 
cause tluTc  will  always  l)e  a  percentage  of  cases  in  whieli  neither  a 
speculum  nor  the  human  hand  can  force  the  anterior  commissure  back 
into  the  field  of  vision.  The  gist  of  the  matter  is  that  an  advance  has 
been  made,  how  great  time  alone  can  settle,  by  the  introduction  of 
suspension.  The  tired  laryngologist  eagerly  grasps  the  relief  which  it 
affords.     (Fig.  120.) 

The  wav  having  been  shown  bv  Killian,  tlie  rest  of  the  world  of 


Fig.   120. 
Killian 's  suspension  niiiiaratus. 


laryngologists  will  rush  in  witii  possible  improvements  of  the  ap- 
paratus, aiming  especially  to  simplify  it.  The  writer  admits  that  he  is 
one  of  those  Avho  have  made  such  an  attempt.  A  hook  in  the  end  of  the 
liandle  of  his  a<ljustable  speculum,  one  nut  and  angle  lever  in  the 
shank,  and  a  set  of  cross  ridges  on  the  moving  blade  convert  it  as  ex- 
perience has  sliowu,  into  a  serviceable  suspension  speculum.  It  can 
be  hung  from  a  chain  attached  to  the  eeiliim'  or  as  Murphy  suggested. 


T..\uvx(i(isc'{)pv.  RiKixciinscorv,  r.soriiAcoscdpv,  ktc. 


KJ!) 


from  tlic  tVaiiio  of  an  iuljiistalilc  iiistnuin'iit  ti'ay  liolilcr.  Tlic  roador 
will  (liiiiiitlcss  think  nl'  ullicr  \\a\s.  The  crane  i>f  Killian  is  enk'ient, 
of  conrso.  but  it  is  luilky  and  doi's  not  lit  every  table.  For  convonicnco 
in  carryinii'  the  writei-  lias  had  a  foMinu'  frame  constrncted.  Tlu'  board 
which  supports  tiiis  slijis  nmliT  llir  liack  nf  llic  patient.  Sn  I'ar  it  has 
mot  oxiieotations.     (Figs.  li!l  and  lilJ.) 


Fig.  121. 
Moslier's   fdldiiig    fiamo    for   stispi'iisinn    :i|.|.:ii;itus   closod. 


Fif?.  122. 
Moslier's  folding  frame  for  s^iispensiiiii  ;i|)i>uiuUis  opoii. 


Ill)  (U'KHATIVK    SriKiKIIV    OF   TIIK    XOSK,    THKdAT.    AN'D    KAII. 

TRACHEOBRONCHOSCOPY. 

The  <lircct  cxaiiiiiiatinii  of  the  Iracln'a  and  the  l)vonclil  can  be  car- 
lii'd  uiit  liy  hvi)  i-(iiit('s.  I-Jy  tlic  iippcr  \ii\\\r  the  tiilic  is  jusortod  be- 
tween the  voeal  cords.  When  tin'  lower  route  is  cnipldycd  the  tube 
gains  access  to  the  trachea  llirough  a  tracheotomy  wdiiikI.  Aft(>r  the 
perfonnance  of  the  tracheotomy  the  second  method  is  tiie  simplci-  and 
so  will  be  described  first. 

Lower  Tracheobronchoscopy. 

Unless  the  lower  route  is  used  for  the  extraction  of  a  foreign  body 
it  is  well  to  wait  a  few  days  until  the  surgical  wound  lias  healed  a  little 


Fig.   12.3. 
Uretlirascope  used  as  .1  tracheoscope. 


before  attempting  thorough  examination  of  the  trachea  and  the  bron- 
chial tree.  The  earliest  examinations  of  the  trachea  by  the  lower  route 
■were  made  through  short  tubular  specula  like  the  female  uretlirascope, 
and  the  illumination  was  obtained  from  a  head  mirror  (Coolidge.)  At 
the  present  time  self-lighted  specula  of  this  pattern  are  made.  (Figs. 
123  and  124.)  For  the  examination  of  the  trachea  as  far  as  the  bifurca- 
tion these  are  the  simplest  and  best  iustrunu'uts. 


l.AUVN'cldSCnIM  .    I!|;i  IM   I  K  ix  t  il'N  .     I>i  in  I  \i  .1 ISCOTV,    I'.TC. 


171 


Contraindications  to  Lower  Tracheobronchoscopy.  Inlos  ir.i 
c-licot(iin\  is  (■nnli-;iiii(lii-;ih'.l  llii'  |n'i-f(>riii;iiicc  nf  liiwcr  1  r.-irhiMilinni 
ell(iscn|iy    is    |icnnissiiilr   f\ri>|il    in    llu'   |  ncsi'llcr   (if   |  ilh'UllKHlin. 

Anesthesia.-  .M'lcr  ;i  iTcmt  ti-aflirnldinv  in  ;i  rase  in  wliirli  tiic 
iiincoiis  nn'inliraiif  is  ihnnial.  a  iir<i|i  nl'  Irn  |iit  mil  i-m-aiii  with  iidrcii- 
alin  aildcti.  pla'-i'd  in  tlir  Iraciica  is  snt'ticiiMil  to  prdihiiM'  aiiostlicsia. 
<  inl\  in  the  r<>^iiin  lirlnw  the  ulnlti-  i-  tliiTi'  rxci'ssive  sensitiveness,  'i'ln' 
Irarhca   hijciatcs   liic   tulic   wi'll.      .M'tcr  tlie  insertion  of  tlio  tnhi'  llic 


Fig.  V2i. 

I'ri'tliraseopc  used  a?  n  tiacliens('ii|ii 

.showing'   iiKiiviiliiiil    parts. 


swal)  syriiiyo  may  he  used  i.,  aii|il\   aiii  In  tlic  walls  of  the  tradu^a. 

the  iiio.st  sensitive  i>ai-t  licinu  the  anterior  wall.  In  ]iatients  who  have 
lieen  wearini;-  a  traelical  cannla  Un-  sipiiic  time  tlic  imicous  nienihrane 
alinut  the  1ul>c  is  Very  in-italilc  and  il  may  he  imjiossiljle  to  coeainize 
it.  in  ciiildrcii  the  strcii.uth  of  the  cdcain  solution  shonld  be  retlnced 
to  live  per  ct-nt  and  in  adults  in  the  iircsmcc  n\'  !ii-nnrlii1  i^  a  twenty  per 
•  •ent  solution  slioidd  not   lie  used  oi-  should   hr  iinpl,,\-,.d  spaiini;ly.     Jf 

thiM-c  is  a  forci-n  \uu\\    in  llir  liarJM.a.  tl M'aini/.al  ion  sliould  be  ac- 

eomplisla'd  with  a  sxriiiyr,  nipt   with  a  swali.     'i'li,'  pari-  of  the  trachea 


17ll  OPKI'.ATIVK    SrilCKIl'l'    111'    TNI';    XOSK,    T 1 1 IM  lAT.    AXII    KAR. 

wliicli  ;iri'  the  nicisl  in-it;il)K'  ;ir<'  the  iiciulilHirlindd  of  the  iistula,  tlic 
liit'urc.-itiiiii,  ;iii<l  the  li|-(iiiclii  lichiw.  The  inllaiiicd  iinicuiis  iiiciiiliraiic 
alHiut  a  t'i)rcii;ii  ImkIv  is  always  st'iisitivc. 

Position  of  the  Patient. — Lower  tiaclicobronchoscoijy  is  easiest 
wlicii  |i('i-loniie(l  witli  tile  patient  sittiii.n'.  After  a  fresh  tracheotomy 
or  if  the  })atient  is  wealv,  the  prone  position  is  better.  When  a  search 
is  to  lie  made  for  a  foreign  body  the  patient  slioi;ld  he  examined  on  his 
liai-k  and  witli  tlie  liead  lowered.  If  the  ])rone  position  cau.ses  congh- 
ing  or  interferes  witli  the  breathing  the  erect  position  of  the  patient 
is  the  only  choice.  Better  control  is  obtained  with  cliildren  if  they  are 
placed  on  the  back. 

In  some  cases  the  examination  succeeds  best  if  the  liead  of  the 
patient  is  extended  over  a  roll  or  if  a  sandbag  is  ]ilaced  nnder  the  neck, 
as  is  customary  in  the  performance  of  tracheotomy.  In  other  cases 
the  head  is  lu'ld  over  the  end  of  the  talile. 

The  Method  of  the  Examination. — The  ideal  method  of  learning 
bronchoscopy  is  to  make  use  of  a  jiatient  who  has  had  a  tracheotomy 
performed. 

The  introduction  of  tlic  examining  tube  offers  some  difliculty  un- 
less it  is  done  at  the  time  of  the  tracheotomy  when  the  tissues  of  the 
neck  are  wide  open,  and  the  tracheal  incision  can  be  spread  with  re- 
tractors. (Figs.  123  and  124.)  After  the  complete  healing  of  the  wound 
about  the  tracheotomy  tube  the  fistula  into  the  trachea  is  more  or  less 
oblique,  and  is  always  narrowed  from  its  original  dimensions.  The 
easiest  way  to  insert  the  tube  without  abraiding  the  edges  of  the  fis- 
tula is  to  place  a  snugly-fitting  elastic  bougie  through  and  bej'ond  the 
tube,  and  then  after  having  inserted  the  projecting  end  of  the  bougie 
through  the  fistula  and  well  into  the  trachea  to  push  the  tube  down  on 
the  bougie.  The  bougie  guides  the  tube  into  the  trachea  and  keeps  it 
from  striking  the  posterior  wall  and  centers  it  in  the  long  axis  of  the 
trachea.  (Coolidge.)  Naturally  the  posterior  wall  of  the  trachea  is 
the  easiest  to  examine.  The  side  Avails  offer  some  difficulty  but  the 
anterior  wall,  especially  in  the  neighborhood  of  tlie  fistula,  is  the 
hardest  of  all  to  inspect.  In  order  to  accomplish  this  tlie  patient's  head 
must  be  turned  strongly  to  one  side  so  that  the  tube  can  be  made  to  lie 
flat  with  the  neck. 

If,  instead  of  inserting  the  tube  downward,  it  is  inserted  into  the 
trachea  with  the  i^oint  upward,  the  beginning  of  the  trachea  and  the 
subglottic  region  of  the  larynx  may  be  examined.  Such  an  examina- 
tion may  be  called  for  in  cases  of  adhesions  between  the  cords  after 
diphtheria  or  when  there  is  subglottic  narrowing  due  to  the  contrac- 
tion of  sear  tissue.    This  method  is  called  retrograde  examination.    For 


i.Ain  ^"l;l•s(•cu'^ .  liiiMNciidscdi'V,  i;sii|'IIai;i)S((H'v.  ick 


17:5 


this  iinict'iluic  sinalli'i-  tiilics  are  iR'cessai'y  in  unliT  lliat  the  hivaliiiiig 
may  nut  lie  iutcrrnccl  witii. 

'I'll  rrluni  1(1  the  .lirci-t  rxamiiintinii  nt"  thi-  hjWcr  ])art  of  tho  tra- 
clica.  ir  it  is  |iiissiliic  111  ciiiiilny  a  laruc  liiln',  just  as  somi  as  this  is 
well  oii.iia,u\'»l  ill  the  hiiiK'H  of  the  trachea  tin-  ol)SL'rvor  usually  can  see 
tho  wlioio  of  tho  trac'lu'a  to  tho  l)ifurcation.  It  may  ho  nooossarv  oc- 
oasionally  to  draw  tiio  tul)o  to  ono  sido  in  onicr  to  aniimiilish  this,  'i'ho 
color  of  tho  trachea  varies  in  dilVerent  paticiits  ridiii  a  yclhiwish  to  a 
blood-like  red.  If  the  walls  nf  the  ti-ai'lu'a  are  painted  with  adrenalin 
solution  loss  li.nht  is  alisorlied  and  tiie  illnniination  is  inereasi'd.  The 
tube  slips  down  tho  trachea  almost  n\'  itself  and  the  liei^inner,  nften,  nii- 


Fi^.  IL'5. 
.J:iclvSon  's  tiioneluiscope. 


Fig.  126. 
.r:U'l<soii 's  liioni'liiiscoiie,  witli  IxncU'd  end. 


loss  ho  keeps  his  boarin.its  ])y  movin.i>'  the  tulie  fnnii  side  to  side,  misses 
the  bifurcation  and  carries  the  tube  into  tlir  rii^iit  main  Inonchus.  In 
this  connection  it  slimdd  lie  Ihh-iic  in  mind  that  the  median  si'ptnni  is 
often  pushed  far  to  \h>-  left.  The  sr|iinni  slnmld  always  be  located  be- 
fore the  tidte  is  ))assed   into  a  liiiim-lins. 

The  Endoscopic  Picture.  In  a  tulmlar  orsau  like  the  tra('ln\a 
liaviniT  a  i-onstant  liiini'ii.  when  tlif  (ilix'rxcr  hniks  tlinm-li  liic  In-nn- 
choscojio  ho  sees  at  .some  distaiiec  ahead  (if  the  end  df  tlic  tnWe  tlie 
lumen  of  the  trachea  and  its  walls.  (  l-'i-s.  l_'."i  and  IJii.)  The  he-inner 
is  liable  to  introduce  the  tube  too  far  at  lii-t  and  not  to  i-ot  the  jiictnrc 
in  persi)ective.  If  this  is  done  iiatlmhiuic  naiidw  inn-  of  tho  Inmen  wonld 
not  be  roco.uiiized.  The  .same  wonid  Ik-  tine  oi'  an\  derorniity  of  tho 
walls  caused  by  pressui-e  of  tho  nei-hhorin-   or-an<.      In  order  to  ob- 


174 


(IPHRATIVK    srr.CEliV    OK   THE    XOSE,    THKOAT,   AND   EAIt. 


Iain  a  ]iro])cr  porspoctive  the  tiibo  sliiniM  lie  liold  lu.uli,  but  for  a  g'ood 
view  (if  the  walls  the  tube  shoubl  be  canicil  well  down  and  as  near  to 
the  wall  to  lie  rxaiuiiii'il  ;i^  pdssililc.  Tile  liiiiiicr  llic  lulic  tlie  larsi'er  the 
field  wliicli  appears  in  jierspeet'n'e  heyinid  it,  the  <leeper  the  tnl)e  the 
smaller  and  clearer  the  lield.  In  order  to  ol)tain  a  clear  picture  of  the 
walls  the  tnhe  shoidd  not  only  he  introduced  w(dl  into  tlie  trachea, 
liut    tile  end   should   be  displaced   strongly   to   the   side.     'I'he    trachea 


Cast  of  the  iutoiior  of  tlie  tiaciiea  and  liiomthi,  witli  tlifir  cliiff  rainifi- 
catioiis  within  tlie  lung.  This  cast  shows  a  type  of  division  frequently  met 
with,  the  right  bronchus  being:  almost  in  continuation  of  the  line  of  the 
trachea,  a,  epartorial  branch;  b.  c.  hyparterial  branches  (ventral  and 
doisal).      (Quaiii.  aftri'  Aeby. ) 

and  the  bronchi  are  so  movable  that  this  y)r()cedure  is  constantly  prac- 
ticed. Indeed,  the  niovability  of  the  bronchial  tree  is  as  important  for 
the  success  of  bronchoscopy  as  is  the  forward  dislocation  of  tlie  base 
of  the  tongue  for  the  perforuuiuco  of  dii'ect  inspection  of  the  larynx. 
In  ])ronchoscopy  the  observer  should  look  ahead  of  the  tube.  The  eye 
should  ijrocede  and  guide  the  tube  and  the  hand. 

The  elasticity   ol'   the    hi-oiichial   trei'   makes   the   lateral   displace- 
ment   by   tlie   examiinng  tube   painless.      The    lateral    mobility   of  the 


I..\l;^  Ni;i>s('(ii'N .   uiioncikiscoI'n,   iosoI'iiacoscoi'V,  v.tv.  h-i 

lu'oiirliial  iri'f  i>  iilili/.cil  to  llic  uTi'Mlot  cxti-iit  in  lniiiuiim  the  lirst 
lii;iiirli  lit'  llic  Icl'l  iiiiiin  liroiiclms  iiitn  \ic\\.  In  ii(l(liti<iii  tlir  \\\\)r  is 
phici'il  in  tlif  i-(Mii('i'  of  llic  iiioutli  Mini  the  licail  nt'  tlic  |iaticiit  is  liciil 
sidowiso  toward  tho  opriator.  The  nu'ciiaii  sc|>luni  <il'  tin'  tradira  ami 
till'  uToat  vt'ssols  sutVi'i'  in  this  iiiaiiiinilatinii  a  ilis|ilacrnii'iit  of  .'i  cni.. 
ami   till'   liroiu'lii   and   iiciii'lilioriiii:-  sti-iictnrcs   a    disliicalidii    nl'    jn  cm. 


Fig.  128. 
C'sist  of  tlio  iiilciiiir  of  (lio  (i:iclie:i  and  liroiii'lii,  with  llioir  cliit'f  lamilicsi- 
tioiis  witliiii  tlie  luii^'.  TliLs  ciist  sliows  a  tvpo  of  diviaioii  less  fi<'i|iieiit  tliaii 
the  la.Ht,  the  riylit  ami  Teft  liroii'Oii  lieiiig  at  about  a  liKlit  aiijilo  with  one 
another,  o,  epaiterial  luanch;  b,  ventral  liyparti-rial  branches:  b',  aecessory 
(nzvgos)    branch:    c,    dorsal    livparlerial    brandies.       ((^uain.    after    .\eliy.) 


The  jiiifrl*'  which  the  tiilic  iiiaKcs  with  the  hmu-  axi.s  of  the  liodv  is  .30°. 
(Fi-  127.) 

Much  loss  dis|ilaciMiicnt  is  iciiniicd  in  ordrr  to  introduce  the  tuhe 
into  tho  third  Iiroiu-hiis  of  oitlior  sidi-.  On  tho  rinhl,  on  ac<-tnint  of  tho 
faot  that  tho  main  hroiichus  is  so  iioarlv  in  lino  with  tho  loii"-  axis  of 


176 


)l'Ki;.\'l"l\K    SIIICKIIV    OK   TIIK    NOSE,    THROAT,    AND   EAK. 


the  Imclieii,  tlio  lateral  (lisiilacciiiciit  siirru-iciit  to  Iniiiii'  tlu>  ln'onclms  to 
tlio  lower  lobe  into  view  is  about  1..")  cm. 

In  lower  l)roiicboseo|)y  even  less  latei'al  excnrsiou  is  necessary. 
(Fi-.  ll'S.) 

The  Interpretation  of  the  Endoscopic  Pictures. — The  greatest  dif- 


Right  recurrent  laryngeal. 


Transverse 
artery 
Right  common  carotia 

artery. 
Suprascapular  artery. 


Thyroid  body. 

Left  recurrent  laryngeal 


Right  coronary  artery 
Thoracic  vertebra 
Intercostal  vein 
Intercostal  artery     ~L 
Vena  azygos  major.  . — 
Intercostal 
Intercostal  artery 
Intercostal  vein. 
Intercostal  artery 


Fig.    129. 
The  arch  of  the  aorta,  with  tlie  i.uhiioiiaiy  artery  ami  chief  branches  of 
the    aorta.       (Morris'    Anatoiiiv — From    a    <lissection    in    8t.    Bartholomew's 
Hospital  Museum.) 

ticuity  which  the  observer  encounters  is  to  judge  the  perspective  rightly. 
As  he  looks  with  one  eye  he  is  without  the  aid  of  the  parallax  which 
binocular  vision  affords  and  is  constantly  mistaking  his  distance.     In 


\..\\:\  MioscoiM  .    r.i;ii\iiiu>(ni'\ .   i:>i)i'iiA<;ns('(H»v,   ktc.  I  t  i 

till'  trat'hra  llu*  oltsrrxrr  ran  lirl).  Iiiiii>rlt'  iiy  o. mil  in-"  tin-  riiii;s.  In 
the  main  Itruiiclii  iiirasiii'i'nu'iils  arc  n\'  iMon-  a'nl.  Tin'  liTcatrst  li<*l|) 
of  all  is  ohtaiiu'il  iiy  layinii"  tlir  niamlriii  ut'  tin-  <^\aiiiinin,u-  tiilx'  nn  thr 
surface   of   tli.-    du'.-t    ainl    Jinluiim'    \\\r    iiiimial    .li^laiicfv    tVniii    tliis. 

'riir  h'imlli  i)\'  a  >1iMiuli('  ai-t-a  i>  liaid  li.  .Irlmnitii'  l.y  >i^lit.  ami 
is  l)csl  iiiiult'  niil  Iiy  ihc  u>('  nl'  a  iin'lal  nli\r  lipiM-.j  huimic  Ohjrcts  at 
the  oiul  ol"  \\\r  lulu'  ajipcar  snialliT  lliaii  1Im'>    rcallN    aiT.     Tlicir  1  riu^ 


Right  commoD  carotid  artery 

Innominate  artery  -A.  ,ir,.  r;\ 
Right  Bubclanan  artery 

Right  innominato  vein 
V    anonyma  dt- xtra 
Superior  vena  cava 
V.  cava  superior 
Right  broDchos 
Bronchus  dexter      --. 


Trachea 

Left  common  carotid  artery 

Left  ianominato  \ 


Cervical  pleura' 
Cupula  pUnir.r 

Arch  of  the  aorta 


Esophagus  (thoracic  portion) 


\|V Mediastinal  pleura 

'.'    ■■■^JAf  I'lcur.i  nu-Ji.ibimal.s 

J         \A  Pulmonary  pleura 

•     >     \\K"       l'l>;iir.-n>ulmonalis 


Omental  tubero^ty  of 
the  liver 

Tnhcr  omcntalc  licpMii 


'Hepatoduodenal  ligament 

or  omentum' 

•Lig.  hcpatoduoJcnate 


Candata  lobe  of  the  liver 
caudatub 
hcpatis 


Showin;;  tlie   iclat 
(From  Toldt.) 


sizi'  (•••111  lie  rcckdiicil  nialliiMMJit  ii-ally,  lnit  il  is  easier  In  ohtain  il  l)y 
ineaslirilli;-  a   iln|iiieate  nf  liie  (plijeet.      (  l''i,i;-.    i;'.(l.) 

The  Choice  of  the  Upper  or  the  Lower  Route.     l'\ir  the  IxvuiiimT 
l'i\\''|-  liMiiieli(i>cn|iy  i>  I'asier  aiiil  -al'ei'.     Ill  iiil'aiils  ainl  ynuiiL;  ehiMreii 

il  is  >al'el-  ami  dftell  the  llletliiiil  of  clidiei'.  The  e\|ierieiicei|  ii|ierat(ir 
will  succeed  with  ll|/|ier  hrunchiisc(i|iy  w  ilere  the  llii\iee  will  fail,  hill 
it  is  well  til  tr\-  llpliel-  hlH||el|(i-i'(i|,y  a>  a  Inlltilii.  in  all  ease>.  IT  it  does 
ll"t    .~l|cei-ed    the  ( i|  mT;i  t  ( iT  ^hnllld    1|(,|    llesilate   \n   aliaildiHI    il    fnl'   the    loWel' 

|-i)Ule.  There  i>  11(1  divuiace  ill  ~,i  ddiiii:-.  It  ha>  heen  |iid\-ed  ihat  ill 
casi'S  ill  which  a  rnrei-n  IhmI)-.  like  a  lii'aii,  has  heeii  playiim'  ii|>  ami 
down  in  the  tracln'a  fni-  sdiiie  liiiie  the  traiiiiia  -n  caii-.eil  (il'leii  |)i-(uluft,'S 
siJJisiii  III-  ecleina  (>r  the  larynx,  so  that  after  u]i|ier  hroiieliosci)))y,  cvon 


ITS 


OPKItATlVE    Sl-i:CiE7tV    OK    THK    XOSE,    TIIKOAT.   AXll    KAi;. 


if  it  has  been  sueeesst'ul,  an  I'liiergoiicy  traclieotdinx-  may  lie  necessary. 
Tile  question  of  ui)])er  oi-  lower  l)roiiclioscopy  slioulil  iicxci-  depend  on 
the  priih'  of  the  opefator  hut  on  the  i>-()od  of  the  patient. 

The  Dangers  of  Bronchoscopy. — Operative  bronchoscoiiy  is  jiatu- 
rally  more  dangerous  than  examinations  merely  for  diagnostic  ))ur- 
poscs.  Jackson's  statistics  of  ninety-four  cases  of  upjper  and  lower 
lu()nchosco]>y  give  a  mortality  of  two  jjer  cent.  The  chief  danger  of 
the  examination  is  its  length.  lender  ether  tliree-quarters  of  an  liour 
is  a  safe  limit.  Bather  than  prolong  the  operation  it  is  better  to  try 
again  at  a  second  sitting.    In  one  of  Killian's  cases  of  a  foreign  bodv 


Rami  broncluales  ventrali 

lobi  superiort5 

Bronchial  branch  of  the  middle 

lobe  ifirst  ventral  hypartenal 

branch  of  the  right  bronchus  i 


i  lobi 


Ventral  bronchial  branches 

of  the  lower  lobe 
Rami  bronchi.ilcsvcritralcs 


Ventral  bronchial  branches 

of  the  upper  lobe 

!     n  I  broncbiales  ventralcs 

lobi  supcrioris 


Ventral  bronchial  branches 

of  the  lower  lobe 
Rami  brnnchi.ilcs  \cnira!c5 


Showiuij  tiic  ilivisions 


;it*  the  traclu':i  and  Inonchi.      (From   Toldt.) 


ill  the  ])i'oncluis  ten  sittings  wore  retinired  l)efore  the  extraction  was 
successful,  and  many  of  these  lasted  two  hours.  Briinings  gives  the 
time  of  the  ordinary  operation  as  five  to  fifteen  minutes.  Jackson  has 
re]iorted  the  removal  of  three  tacks  in  tliree  minutes.     (Fig.  131.) 


i,Ai;\  ^•l;^s^■ll|•^ .   iu;(inciiii>('ii1'\  .   lmH'iiacoscoim-.  ktc. 


i7;» 


Asepsis.  Ill  InuiicluiM'tiiiy  tlic  numtli  i>\'  the  imlicnl  sIkhiIiI  I.c 
iiKulo  as  flcau  as  possililc.  .lacksdii  ail\-isi'S  a  ihiily  \>r]-  cciil  Miliilimi 
of  alciiliiil   as  a   iiKUiIli    wash.      It    <;iics  witlidiit    sa\inu   that    tlu'   iii^lni 


Fig.  132. 
Sliowiiiy:   tlic   lolalidii    of   tlio   nuiiu   bioiiehi    to   the   rilis   jiiul    the   lOiest 
ttall   (Anterior  view).     (From  Ansitoniicnl  Dciiartiiient.  llarvanl  Meilii-iil 
School.) 


incuts  jilso  slioulil  he  cli-aii.  (iciicrally  iiniiiiT>i.iii  in  -cxciity  )icr  c-ciit 
alcoliol  is -(IcjHMKled  u])oii  Tor  the  stciili/.atioii.  |-"(innaliii  vapdi-  can  lie 
^-niploycd  if  |iifri'rrc(l. 


180  OPKRATIVE    Sl-RCiKKY    OF    THE    XOSK,    TIIUOAT,    AND    EAK. 

The  Size  of  the  Tubes. — Biiiiiings  uses  tulx's  of  four  sizes. 

Ul'PER  BuONCnOSCOl'Y. 

XuiiibiT                                      Size  Age 

1      7       mm 1  to    3  years. 

1% 7V>  mm 4  "     5  "  " 

2      S14  mm 4  "     0  " 

:',      10       mm 9  "  14  " 

4      ^2       mm \ihilts   (men  and  women). 

Lower  BiiONCiroscoPY. 

Xiniilii'r  Size  Age 

1      7       mm 1   to    3  years. 

L'      . S 1/0   mm 3  "     S   '  " 

?.      10       mm S  "  14      " 

4      12       mm Adults   (men  ami  women). 


BRONCHOSCOPY. 

In  order  to  see  the  secondary  bronchi  the  main  bronchus  is  dis- 
located laterally  and  the  tnbe  brought  into  line  witli  the  bronchus  to  be 
examined. 

The  patient's  head  must  be  lient  in  the  lu'ojjcr  manner  to  allow 
this  change  in  the  position  of  tlie  tube.  In  changing  the  position  of 
the  head  the  neck  should  not  be  held  far  backward  and  cramped  be- 
cause tliis  interferes  with  the  mobility  of  the  trachea  and  the  bronchi. 

As  soon  as  the  lumen  of  the  right  main  V)ronchus  is  entered  and 
lighted  by  the  tube,  the  observer  sees  in  the  distance  the  opening  of 
the  bronchus  to  the  lower  lobe  and  within  this  smaller  dark,  oval 
patches  Avliich  are  the  openings  of  the  tertiary  bronchi.  Between  these 
dark  patches  appear  the  median  septa.  The  picture  constantly  changes. 
With  every  movement  of  the  tulie  new  openings  of  noAV  branches  come 
into  view,  in  the  dejhlis  of  which  other  divisions  are  seen.  (Fig.  133.) 
In  the  deeper  lironchi  there  is  a  rliytlunical  cliangc  of  t]\v  picture  with 
I'espiration. 

When  the  tube  is  jjlaced  high  in  the  main  bronchus  the  opening  of 
the  branch  to  the  uj^per  lobe  as  well  as  of  that  to  tlie  middle  lobe  gen- 
erally are  not  seen.  It  is  cnily  after  inserting  the  tube  to  the  ]3roper 
depth  and  dislocating  the  bronchus  between  one  and  one  and  five- 
tenths  cm.  to  the  side  and  upward,  that  the  lower  circumference  of  the 
opening  of  the  branch  to  the  upper  lohe  is  discovered.  If  the  manipu- 
lation is  not  successful  the  tube  is  inserted  below  tlie  origin  of  the  first 
branch  and  lateral  pressure  is  made  as  before  and  the  tube  withdrawn. 
As  the  tube  comes  up  the  opening  of  the  bronchus  springs  into  view. 
(Fig.  134.) 


LAnvNcnsiiii'N ,   r.i:i  iNC!  insc(ii'\ ,   i;sni'iiAi;iisriii'\ ,   i:rt'. 


ISl. 


II 


■f.  --Jl 


182 


OPKUATIVE    Sri'.CKKV    OK   TIIK    XOSE,    TIII'.OAT.    AND   KAK. 


Diaj,'r:im  to  sliow  the  bioiielKJSt-ciiiic  iiii-turc. 
(After  Jackson.) 

A.  The  bifurcation  of  the  trachea  is  sliown 
to  the  left  of  the  middle  line.  1.  Left  main 
bronchus.     2.  Right  main  bronchus. 

E'.  Picture  of  the  left  main  bronchus  (see  Fij;. 
128).  1.  Bronchus  to  upper  lolie.  2.-.'i.  Bronclii 
to  lower  lobe. 

C.  Picture  of  right  main  bronchus.  1.  I^rduclius 
to  upper  lobe.  2.  Bronchus  to  middle  lubo.  1.-4. 
Bronchi  to  lower  lobe.  No.  4  is  the  practical  con- 
tinuation of  the  right  main  bronchus. 


Ill  luWiT  lir(ilicll(iscn|iy  lllO 
ii|M'iiiim'  111'  the  liraiicli  to  till' 
u])])*'!-  ]()))(•  i.'<  easier  to  liiitl.  So 
readily  can  the  opeiiiii.u'  l)c  ap- 
proached tlial  the  cireuinfer- 
ciice  oT  Ihc  lirsl  two  I'iiiii's  can 
he  made  out.  The  Held  often 
increases  rhythniii-all\  with 
the  res])iration. 

The  cavity  of  the  lii'aneli  to 
the  upper  lobe  can  be  explored 
by  placing  a  small  mirror 
through  the  examining  tube 
into  the  bronchus  or  by  insert- 
ing a  small  cystoscope.  AVith 
the  latter  Briinings  has  dem- 
onstrated even  the  tertiary 
hronclii.  The  cystoscope  should 
have  a  diameter  of  8  mm.  and 
if  designed  for  both  upper  and 
lower  bronchoscopy  it  should 
be  about  30  cm.  long. 

Although  cases  have  been 
reported  of  foreign  bodies 
lodged  in  the  branch  to  the  up- 
per lol)e  (Wild  and  Gottstein), 
as  a  rule  such  cases  are  rare. 
Killian  calls  attention  to  the 
fact  that  the  examination  of 
this  branch  might  give  a  clew 
to  tuberculosis  of  the  right 
apex,  that  is.  pus  might  be  seen 
coming  from  the  opening  of 
the  bronchus  in  such  cases. 
(Fig.  134.) 

The  direct  examination  of 
the  branch  to  the  middle  lobe 
is  easily  accomplished  when 
the  tul)e  is  carefully  introduced 
and  pressure  is  made  in  a  for- 
ward direction.  This  opening, 
hoAvever,  can  be  readily  con- 
fused with  that  of  the  branch 


l.Ain  X(i(lS((i|'V.     Ili;ti.\<-||(IS((I1M  .     i:>n|'|l.\i;nS(illM  ,    ICTC. 


18:; 


t(i  iIh'  Iciwvi-  lol.c.  In  all  cmscs  in  wliidi  llic  olisciv  .t  is  in  iImhIiI  iIk 
tiiho  slnmld  lie  w  it  lidraw  n  In  lin'  liifiircat  ion  ami  Ilim  caiiicil  duwii 
\varil  anain  stcii  li\   step. 


Fig.  135. 
DiiiKr.-mmiafic   ilrawiiig   tci   .show   the   bioiichospopic    picliiro   at   various   Ipvols. 

The  in-aiicli  t>\'  the  rii^lit  main  bi'dnrlins  In  the  lower  IuIm'  i-  irally 
a  cnntinnatinn  n|'  tlic  main  Ihhim'Iiii-.  I'm-  this  reason  llic  dinMiin'^  «\' 
tlie  tliinl  Mcmdai-x  ln-miclni.-  i>  nn|  nnly  easy  tn  sec  and  ciilcr  witli 
'!!'■  'iiIm'  Km  thi>  i-  III,.  l.innrlni>  w  liicli  most  (iftrn  catcln-  fnivii^'ii 
lH>di,.>.     (  l-'io'.  i;;.-,.) 

TIh'  Ii'I'I  main  linmclms  k-avcs  tiic  trarln.a  nincli  nnnv  sharply  tlian 
llir  riyiii   liidiiclnis  docs.     For  this  reason  it   is  iiai'dci-  in  naiii  access 


184 


OPEKATIVE   SUIUiKllV   OF   TIIK   XOSE,   TIIIiOAT,   AND  EAR. 


of 

s 

S 

- 

- 

i 

^ 

M 

ef- 

y. 

a 

... 

ce 

c 

-^ 

t- 

£ 

s 

Tt 

!° 

3 

rt 

— 

1 

rH 

> 

c 

^ 

::^ 

c 

< 

c 

^^ 

3 

% 

o 

'"' 

p 

K 

\ 

p 

> 

1 

o 

"S 

^ 

K 

p 

< 

tj 

tri 

O 

S 

j: 

+-» 

f4 

9 

^ 

% 

«H 

-    gH     C'     ?     C     i. 


.  §:".S    .< 


''•  H  =«  ,5  £  .y 

■gig  «  ^  .-? 
=  ^  --£  S  ■§)(£• 


£         g  a  cs  ^"  •  -  a 


2  S-i3  >>;;  g. 

^  L,  a  3  -p  « .i:; 

::  = "  3  "^ 

""  r-;    .-ai  ■•:<  a  oi 

^+^  "  hJ    .  rt  p-  ^ 

■*?  °  ^4  ^'  >4   '^     r 

S  >,   .  S  <i<    rK 

S  a  Q  a  i  >.   .  S 


LAIIYXliOSCOrV,    r.i;ONC'IIOSC(»I>V.    KSOIMIAUOSCOPY.    KTC", 


185 


to  it  ;in<l  t(i  liriiiir  its  )iiMiiciics.  especially  the  lii'st.  into  view.  Tiiis 
lii-diiclms  is  easier  to  see  liy  iowei-  l.roiiclin.-c(.| iv.  In  investigating  the 
li't't  main  liroiu'hus  sti'onii-  pnlsations  fitini  llie  aieli  ul'  the  aoi'la  ai'e 
noticed.     (  Fig.  136.) 

The  origin  of  the  ln-aneii  <<\'  the  left  main  Innnciins  to  the  npiiei- 
hilie  i>  4  to  .")  cm.  from  the  hilnrcaticin.  It  i-  to  he  fnun.l  on  the  lateral 
wall  and  >omewhat   anteri.)r!y.      It    is  often  missed  hoth  on  the  inser- 


Fig.  137. 

Hiirizontal  section  of  thorax  of  man,  aged  57,  imnioiliatoly  alio\e  tlie 
liifuifation  of  tlie  trachea,  seen  from  ahovc.     (From  Quain.) 

U.  L..  upper  lolie  of  right  lung;  U.  P.,  L.  L.,  upper  and  lower  lolios  of  loft 
lung:  K.  B.,  L.  B.,  origin  of  right  and  left  bronchi,  in  this  specimen  the  ter- 
mination of  the  trachea  was  lower  than  usual;  A.,  arch  of  aorta;  D.  A., 
descending  aortti;  D.,  obliterated  ductus  arteriosus;  N.,  left  recurrent  lar^^l- 
geal  nerve;  L.  G.,  lymphatic  glands:  other  letters  as  in  Fig.  1.36. 


tion  and  on  the  withdrawal  of  the  tnhe,  and  a  sight  oi'  it  is  to  he 
gained,  if  at  all.  Iiy  stmn-  l;iter;d  and  npward  dislocation  of  tln'  main 
lironclms  and  with  the  en<l  d'  the  tuiie  held  ;is  olili((nely  to  the  lateral 
wall  as  jiossihle.  .\atnrally  foreign  hudies  do  not  often  gain  entrance 
to  this  Vjronchus.     (Fig.  l.'!7.) 

On  the  left  the  secoml  hi-ancii  of  the  main  hr(nichns,  the  hronelms 
to  the  lower  lohe.  is  f(ir  all  intent^  and  |inr)io>es  a  i-dnt  innal  ion  nf  the 
main  hronclin-.  'i'he  tnlie,  i  hereluii',  iind>  it  rc;idily  and  the  |iictnre 
seen  throngh  tiir  tidie  simws  tin-  iunieii  nf  the  thii-d  hraneli  :iiid  then 
the  division  into  tlie  dorsal  ami  vrntial  hi;ineiies. 


isd 


()i'i';i!ATi\'i':  sritdKin'  ov  tiik  xose,  TuitoAT,  and  ear. 


Lower  hronclioscopy  carried  out  as  lias  liccii  imlicatcil  is  imt  difli- 
<'ult.  The  broiielii  should  be  examined  lioth  (ni  the  iiili-ddiirtidn  i,\'  the 
tui)e  and  on  its  withdrawal.  The  cxaMiiiiatiuii  cannot  In-  considcicil 
(•otni)lete  nidess  both  main  lironchi,  the  secondary  lironchus  nu  llic  riL;lit 
to  the  middle  lobe  and  the  branch  1o  the  lower  Inlie  on  hoth  sides  have 
lieen  examined.  The  exploration  of  the  two  main  hrunchi  and  the 
branch  to  the  lower  lobe  on  the  lin-ht  is  especially  demanded  because 
foreis'u  bodies  often  lod.no  in  them,     in  the  authoi's  experience  furei.ii'u 


Fig-.  1.38. 

Hoiizdiital  >:fcticju  of  t)ic  thorax  of  a  luaii,  ag'-d  .17,  at  tlie  level  of  the 
loots   of   tlie    liiiijjs,   seen    from    a!)Ove.      (From    Quaiii.) 

I.  S.,  superior  and  inferior  lobes  of  lungs;  £.,  eparterial  lironehus; 
A.  y\.,  anterior  mediastinum;  E.  P.  C,  right  pleural  cavity;  P.  C,  pericardial 
cavity;  A.  A.,  ascending  aorta;  P.  A.,  i)ulinonary  artery;  R.  P.  A.,  its  right 
Ijranch:  K.  I'.  V.,  L.  I'.  V.,  right  and  left  pulmonary  veins;  A.  V.,  azygos 
iii;i.jnr    \eiH;    other   letlers   as   in    Fig.   VMi. 


bodies  lodge  oftenest  at  the  hifurcation  of  the  trachea,  in  the  dilatation 
where  the  first  branch  of  tiie  ri^'ht  main  bronchus  comes  off,  or  in  the 
internal  branch  of  the  bronchus  to  the  lower  lobe. 

The  tertiary  bronchi  are  so  small  that  neither  the  bronchoscope 
nor  light  can  In'  made  to  enter  them.  In  such  cases  the  use  of  a  sound 
will  enable  the  operator  to  palpate  these  small  tulies  even  to  the  ]iei-iph- 
ery  of  the  lungs.     (Fig.  ^oH.) 

Lower  bronchoscojiy  is  easier  witli  the  patient  in  tlu'  sitting  posi- 
tion.   It  can  and  often  is  carrieil  out  with  the  p;itieiit  lying  on  his  back. 


i..\mN"i;nsc(ii-\'.   iiKdNciiosciii'N .   i;s(Pi"ii.\i;nsi  i)r\ .   i:ri 


\<, 


It   is  li.-uilci-  111  iiiniiaiic  tlu'  imsitioii  ol'  llic  pntirnl  '-  lir.-id  i!'  lie  i<  iipmi 

llis   li.-ick.    lirr;msc   llir    ll.-llhllr   <if   tllf  .■Icct  I-c.Sc..|  .r   ul'trli    -cts   ill    \\\r   \\;iy. 

(l''iL:.   ]■''■'. \      With   llic  .l;i.-i<Min  IiiIh',  li.iw cxn-.  tliis  (liHiculty  i-  not   rii 

♦•oUIltiTril. 

Upper  Bronchoscopy. 

rpju'i-   lir()iicli(isc(i|iy    i>   iiiiicli    innir   (lilliciilt    tli;iii    Ihwit    liniiirlio 
scopy    nil    ;li-C(UlIlt    nf    tlli'    lllnrc   ci  im|  ilirji.t  I'l  1    li'clinic    Iriinircd    to    insert 


^      \ 


\\ 
J 


FiK.  i.in. 

Horizontiil  section  of  tlic  thorax  of  a  man,  agecl  57.  mi  iIh-  li\rl  of  tin' 
iiiliplos,  scon  from  nliove.  Xntc  liow  tlip  lnonclii  Jsepp  near  the  nieiliaii  line. 
Tliis  is  fortunate  in  tlie  removal  of  foieign  Imdie.s.     (From  Quaiii.) 

n..  nipple;  M.,  middle  lolie  of  riyht  lunn;  B.  A.,  rijjlit  anriele;  R.  V., 
ri^'lit  ventricle ;  L.  A.,  left  auricle;  L.  V.,  left  ventricle;  K.  V.  P.,  riglit 
posterior  valve  of  aortic  oiitice;  r.  />.  <•..  riylit  pleural  cavity;  other  letters 
as  in  Fiji,  l.'ili. 


tile  Iir(iiir|i(,sc(,|i...  ,|ni.  t,,  ih,.  iniin  (if  the  l;ii->n\.  ;iiii|  hccnnsc  i^\'  tlu' 
sli.uiiter   niDliilily   of  ihc   tnl..'  ;iihI    it>   -ivjit.T   Icii.ulli. 

Anesthesia,  'rin-  (icrni.-m  schnnl  arr  slrnim  a<l\ncatcs  nf  l(ic;il 
iiiicslhcsia  ami  the  sittinj;  jxisitioii  ol'  thr  patimt  iluiiiiL;-  the  '•\;iiniiiii- 
tioii.  In  this  ciiuiitiy  nciicral  Miicsthcsia  is  n-rd  hir^rly  ;incl  tlic  pa- 
tient is  f.xaiMincd  lyiii>r  on  liis  liack.  The  n>c  nf  dlicr  (loi'.s  jiway  with 
the  sense  of  hurry  which  attends  liKmi'liux'dpy  niKh-r  local  anesthesia. 

The  Method  of  Performing  Upper  Bronchoscopy.  If  hical  anes- 
thesia is  to  1)1'  cnipioNcd  the  iaiviix  of  thi'  paiirni   i-  i-i i.'ai iii ;'i'd   as  for 


188  ni'KiiATivE  snuiEnv  of  the  kose,  throat,  axd  eak. 

direct  iiis|i('cti(iii.  'I'lie  refiexos  of  tlic  larynx  arc  llic  niosl  active.  After 
the  aiiestlicsia  has  l»een  accoin])lislic(l  the  vocal  cords  nvv  exposi'd.  If 
Briiniiiiis'  instruments  are  selected,  this  is  done  with  the  tul)uhir  spa- 
tula used  after  the  fashion  of  his  speenhini,  em])loyed  for  direct  ins]iec- 
tiou  of  the  L-u-yiix.  It  is  not  necessary  to  expose  the  anterior  connnis- 
sure,  so  that  the  operator  is  content  witli  disclosing'  the  ])osterit)r 
third,  or  tlie  posterior  half  of  the  cords.  If  this  much  is  not  read- 
ily Vironght  into  view,  the  assistant  pushes  the  larynx  backward. 

The  pjassage  of  the  larynx  is  the  difficult  part  of  the  mani])ulation. 
This  is  best  accomidislied  by  cautioning  the  patient  to  breathe  quietly 
and  regnlarly.  When  he  does  this  the  cords  part  in  ins])iration  and 
the  tul>e  is  slipped  between  them  and  into  the  trachea.  The  cords  need 
not  l)e  widely  separated.  Sometimes  it  is  necessary  to  turn  the  spatula- 
like edge  of  the  speculum  anteroposteriorly  and  to  insert  it  in  this 
manner  between  the  cords  and  then  to  turn  the  speculum  and  force  the 
cords  apart,  'i'he  introduction  of  the  warmed  and  oiled  tube  is  brought 
about  not  so  miich  by  force  as  by  manipulation  and  a  lever-like  move- 
ment of  the  tube  under  the  guidance  of  the  physician's  left  foreiinger. 

The  Introduction  of  the  Bronchoscope  with  the  Patient  Lying:  on 
His  Back. — Where  the  jiatient  is  placed  on  his  hack  it  is  necessary  for 
the  introduction  of  the  tube  to  have  the  head  held  over  the  end  of  the 
table.  After  the  tubular  speculum  has  passed  the  ujjjier  i)art  of  the 
epiglottis  the  head  must  be  lowered  for  the  exposure  of  the  cords  and 
the  passing  of  the  tube  between  them. 

In  the  prone  position  of  the  patient  the  handle  of  the  electroscope 
is  somewhat  in  the  Avay.  This  difficulty  is  not  encountered  if  the  Jack- 
son tubular  speculum  is  used  because  the  speculum  is  discarded  as 
soon  as  the  bronchoscope  has  entered  the  glottis.  If  the  introduction 
of  the  tube  is  difficult  the  patient  may  be  turned  on  his  left  side.  The 
tubular  speculum  is  then  carrie(l  in  from  the  left  corner  of  the  month. 
The  head  is  unsupported.  The  si»eculum  easily  passes  into  the  tra- 
chea. After  the  si)eculum  has  entered  the  trachea  the  ])atient  is  turned 
upon  his  back  again  and  the  examination  completed.  The  cords  hav- 
ing been  passed  the  rest  of  the  examination  is  carried  out  as  in  lower 
bronchoscopy.  When  the  tubular  speculum  lias  ex])lored  the  trachea 
to  the  bifurcation  the  inner  tube  is  inserted  and  advanced  step  by  step 
to  the  main  bronchi.  Naturally  it  is  not  possible  to  move  a  tube  when 
passed  from  tlie  mouth  as  much  as  a  tube  introduced  through  trache- 
otomy wound.  Therefore  there  is  less  lateral  dislocation  of  the  trachea 
and  the  bronchi.  To  make  up  for  this  loss  the  alteration  or  moulding 
of  the  patient's  body,  chiefly  the  ])ositiou  of  liis  sjiine,  is  called  into 
plav.    The  bronchoscojie  is  sliifte<l  to  the  corner  of  the  mouth. 


I.Al;v^■|;()S(■MI•^ ,   I'.iKiNciiitscoi'Y,  i;soi'iiai;iisi'(ii'V.  vvrr.  1S!J 

Upper  Bronchoscopy  with  the  Jackson  Tubular  Speculum  and  the 
Jackson  Bronchoscope.  Tlu-  l\il)ul;ir  sin-i-uhiiii  of  JiK-Usun  is  vci\  nui 
voniont  for  (.'Xposiiiu  Ilic  larynx  and  for  introducing  the  broncliosi'opc'. 
Jac•k!^on  until  ivoi'iitlx  lias  picfriicil  to  pass  tlic  hronchoscopc  umcUt 
,a:i'noral  aucstliesia  and  with  tlic  patient  lyini;'  on  liis  liai-k.  Lately  he 
has  discarded  both  local  and  general  anesthesia.  The  experience  of  the 
writer  of  this  aHicle  lias  heeu  ohlaincd  almost  wholly  with  mineral 
anesthetics.  After  the  cords  iia\e  been  exposed  with  the  tnhnlar  spt'c- 
nluni  a  bronchoscope  of  the  self  liuhtini;-  jiattein  and  of  apjudpriate 
size  is  passed  through  the  specnhnn  and  iK-tween  the  cords.  Then  the 
sei)arable  hood  is  removed  and  the  specnhnn  withdrawn. 

The  Introduction  of  the  Bronchoscope  with  the  Open  Speculum. 
— The  introdnction  of  the  bronchoscope  with  the  ad.jnstable  open 
s])eculnni  of  the  antlior  is  the  simpli-sl  method  of  ])assing  the  broncho- 
sco)ie  nnder  \ision. 

The  Examination  in  Children. 

Owing-  to  the  liexii)ility  of  the  neck  in  the  rhild  and  to  the  shorter 
distances,  the  direct  ins]iection  of  tlie  lar>n\  in  infants  and  childi'eii 
is  often  com|iarati\fly  eas\ .  The  vtrnctiires  are  diminntive  so  that  the 
field  obtainetl  is  small.  'i"he  epii^lottis  is  nnde\elo]ie<|  ami  often  very 
iniruly  when  the  specnhnn  attempts  to  control  it. 

The  difficulties  in  the  examination  of  children  arise  fi-oni  the 
smallness  of  the  structures  wjiich  necessitates  tubes  as  small  as  ()-7  nnn. 
Through  tiiese  it  is  hard  to  get  a  good  view  and  to  manipulate  instru- 
ments. In  addition  the  examiner's  ditlicnlties  aic  increased  by  the 
unndiness  ol'  the  patient,  by  tlie  tcndeni'y  to  sjiasni,  by  sabnation,  by 
tlie  strong  respiratory  mcixemenls  of  the  trachea  and  the  brinichi,  and 

lastly   by    the    greater   tendency     to   collap-e    either   with    hieal    o|-   gelliTal 

anesthesia. 

Tn  most  cases  bi-micliosedpy  i^  undertaken  in  ehijdi'i'n  for  tlie  de- 
tection and  the  rcniii\al  nf  foniLMi  bcdies.  foreiizn  boilies  are  most 
connnon  in  eliildrcn.  U\  >nniniai-i/e  a  table  fiMni  (iottstein.  between  the 
seeoiul  and  the  sixth  year.  Sixty  nine  pei-  cent  of  cases  occur  l)efore 
the  twelfth  \car.  and  oiil>  thirty-eight  per  cent  fi-om  the  twelfth  year 
onward. 

Instruments.—  Ixelatively  wider  specula  may  be  u.sed  in  cliildren 
than  in  adnlts.  Forceps  iunl  all  other  instruments  which  are  to  be  used 
tlirough  the  diminutive  tubes  which  are  employed  in  children  must  be 
especially  snudl  in  calibre.  Hrunings  has  a  sjjccial  form  of  electroscope 
wliiili  lie  advises  for  this  work'.  Other  instrnnients  are  the  open  si>ec- 
nlnni  nf  I'riinings,  or  that  of  the  wi'iter.     A  self  liiihted  urethrascope 


1!">  lil'KKATIVK    sntCKIIV    OF    T  M  K    XOSK.    Tlli;()AT,    AND    KAI;. 

is  of  serxirc  Inr  use  tliidiiuli  ;i  tr.-icl Inmy   woinnl.     The  siz.'  (if  such 

tnbos   \';irics    liclwccii    7    niid    S    imn.      'I'hc    sizes    nl'   the    uicl  lii-ascopcs 
should  lie  ."),  i;  ami  S  uiiii.     Scxciilcni  cm.  is  a   suriicinit    Icimtli    I'oi'  Ihc 

foivrps. 

Direct  Laryn^osccpy.  'I'iic  simplest  way  to  cxamiiu^  a  l)al)y  is  to 
wrap  it  ill  a  Maiikct  and  to  place  it  on  its  liaclc  on  a  tahlc  and  expose 
tile  larviix  with  the  open  specnlum  or  the  childreirs  size  of  the  Jack- 
son speculinii.  'Idle  examination  of  tlu'  child  held  'ii  a  sitting  posture 
in  the  ai-ms  of  a  nurse  is  also  satisfactory,  i^'or  this  purpose  tlie  spec- 
nlum is  ])assed  along  the  center  of  the  tongut'  or  introduced  from  the 
cornel-  of  the  month.  In  infants  and  children  the  author  lias  had  no 
exju'rience  with  local  anesthesia.  He  prefers  to  use  general  anesthe- 
sia. Briining's  gi\'es  the  imju'essiou  that  examinations  conducted  in 
this  Avay  are  less  satisfactory  than  when  local  anesthesia  is  iMiijiloyed. 
It  is  douhtfnl  if  the  exjierience  of  ojierators  in  this  coTiuti'v  accords 
with  that  of  Briinings. 

The  Method  of  Examination. — The  method  of  making  the  direct 
inspection  of  the  larynx  in  infants  and  children  is  the  same  as  in  adiilts. 
The  distances  are  very  short  and  the  epiglottis  is  ])laced  high  so  that 
only  a  slight  depression  of  the  tongue  is  reqnii-ed  to  exjiose  it.  The 
pharynx  and  even  the  glottis  often  close  in  a  s])hincter-like  fashion, 
and  from  time  to  time  the  whole  Avorking  held  is  Hooded  with  mncns. 
A  speculum  with  a  liroad  end  is  especially  serviceable  in  raising  the 
stidthy  and  elusive  epiglottis.  Often  the  anterior  commissure  of  the 
larynx  can  l)e  moulded  into  view  by  external  ))ressure.  In  holding  th<3 
head  it  should  not  be  l)ent  too  far  liackward. 

Lower  Bronchoscopy. — Lower  bronchoscojiy  is  can-ied  out  wit'i 
children  in  the  s;iiiie  manner  as  in  adults,  for  the  examination  of  tlu; 
ti'achea  in  the  neighboihood  of  the  Hstula  tlie  urethrasco])e  or  a  small 
bronchoscope  constructed  on  this  jjattern  is  of  service.  In  examining 
the  trachea  and  the  bronchi  the  respiiatoi'v  movements  of  the  air  pas- 
sages ai'e  a  great  annoyance.  In  strong  res]iiration  the  Held  may  be 
lost  altogether.  This  is  embarrassing  in  the  bronchi  because  if  the 
mucous  membrane  is  swollen  it  is  only  during  inspiration  that  a  view 
can   be  obtained. 

Upper  Bronchoscopy.  -  I'liper  lironchosco|)y  in  children  is  the  most 
difficult  feat  which  is  attempted  with  this  procedure.  'I'he  examiner 
should  1)1'  ready  and  willing  at  any  momeiil  to  sn]))ilaiit  it  hy  lower 
bronchosco])y. 

The  jiuthor  lias  had  most  experience  with  upper  broncdioscopy 
performed  under  general  anesthesia.  Small  doses  ot  ati'opin  control 
the  secretions.     The  intioduction  of  the  tube  is  easily  accom))lished  in 


I.AUVNiinsCnI'V.    llllnNCIIOSCOl'V.    KS(  (I'll  ACI  ISCOI'V.    IVW. 


11)1 


llii"  iisiuil  i-;is.'  witli  tile  >iii;iil  .larksmi  siirciiliini  ur  willi  tlir  .•kIJu.-I.iMc 
open  spociiliiiii.  I'lipi'i-  l)i-.inciii)-cciiiy  in  rhilihcii  >li(niM  iirvcr  !»■  ;it 
tciiiiilcd  \vitliii\U  iiistniiiii'iil^  aiiil  ;is>i>t;ml>  ciinnuli  I'm-  ihc  r\ccii1iuii 
of  .-i  v:\\>\i\  tr;iclif(ilciiii\-.  'I'lir  il;iiiL;fr  "\'  suli-l«i1 1  ir  >\\clliii'-;  .-il'li'i-  ludii- 
(•linscMipy  in  vliiiilnMi  sIumiM  alw.-iys  lie  in  llic  minil  nl'  iji.'  diFiTntur.  The 
liatiiMit  ni;iy  ivtiuii-f  an  cnnTui'nc)  l  lai-lu'dli.nis  imi  .mly  durin-  tin- 
operation  hut  <\\  any  time  dnrini;  tlu'  nv\\  day  n|-  two. 

Tlio   .ui'iicral   conduct    nf  the   examination    liy    ihr    npper    mnlr    i> 
aloni"-  tile  sanu'  lines  as  iIh'  exannnalinn  in  the  ailuit. 


Instruments  for  Bronchoscopy. 

Tlie  essential  instiunient  for  liie 
perrornianee  of  direct  insjiection  i<\' 
the  larynx,  tlie  liachea.  and  the  liron- 
chi,  is  a  inelal  tnhe  of  a|iprn|iria1e  >i/.e 
aud  leu,e:th.  Km-  dii-e<-1  examinaliini 
of  the  larynx  the  tulmlai-  sprcnhiin  i.- 
constniete(l  so  1liat  it  is  open  foi-  a 
])art  of  its  leiif^tii.  i-"or  lin'  e\aniina 
tion  of  the  hrouchi  tlir  spciMdnni  he 
conies  a  h)n,ii-tuhe.  The  speciilnin  and 
the  lon.ir  tuhe  can  he  lii;lited  from 
within  or  from  without.  The  simplest 
method  of  liiihtiuii-  the  hroncimscoite 
is  that  ])opulaii/.ed  hy  .larkson.  A 
small  secondary  tniie  is  (■anie<l  alonu 
tiie  side  of  the  lari,^er  and  the  main 
tuhe  to  its  lower  end.  .\t  tiiis  point  a 
window  turns  tie'  Inmcn  of  hotli  tuhes 
into  one.  hi  thr  secondary  Inlie  a 
small  rod  like  tuhe  acts  as  a  cai-ricr 
for  a  diminnti\c  cloi-tric  lain|i.  When 
the  carrier  is  in  position  the  lamp  lie>  opposite  the  window  and  when 
the  lam|i  is  Inii-iiim;'  its  liuiit  iliinniiiates  not  only  tlie  end  of  the  lai-ii'er 
tuhe  hut  shines  ahead  of  it. 

The  illumination  of  tln^  tnlie  iiy  the  second  method  is  accomplished 
hy-  attaching!:  to  a  lumdle  w  hieli  can  hold  various  sizes  of  tuhes,  a  small 
i)ut  jiowerful  electric  lamp.  (  Fi;.;.  1411.)  Ahove  this  a  mirror  is  so 
|)laced  that  the  lifilit  from  the  lamp  is  thrown  down  and  throuiih  the 
tuhe.  Briiniufjs  has  (Ievel(>|)ed  this  form  of  illumination  to  a  hinh  dcii'iee 
of  efticieucy  in  his  various  forms  of  electroscopes,  iiotli  metlnuls  of 
liirlitinir  the  examininu'  tuhes  are  hiiihlv  successful.     Kach  has  certain 


ria.  ]-in. 

Hiiiniiij;s'  cli-ctroscdpc. 


192  OPEKATIVK    SriiGKI'iV    OF    Tl  IK    XOSK.    TIIIIOAT,    AND    EAR. 

advanta.i^'os.  Tlic  exaiuiiuT  sliduld  ^ifdvidc  liiiuscll'  with  lioth  sots  of 
instriinieiits.  Ili'  certainly  slanild  not  allnw  liiniscll'  td  liccduic  so  prej- 
udiced as  to  be  willing  to  use  but  one  i)attei-n. 

'Pile  disadvantage  of  the  self-illuminated  tul)e  is  that  the  light  is 
liable  to  become  clouded  Avith  secretions  and  blood.  It  is  surprising, 
however,  especially  if  the  examination  is  contUieted  under  general 
anesthesia  and  the  secretions  conti'olled  by  atropin,  how  long  the  light 
will  burn  before  it  becomes  dimmed.  As  a  rule  suction  will  keep  it 
clean.  Theoretically  a  strong  case  can  be  made  out  against  the  self- 
lighted  tube  in  the  presence  of  abundant  secretion,  especially  blood, 
but  the  results  of  practical  work  refute  most  of  the  objections.  The 
lights  call  for  a  little  more  care  than  the  larger  lamp  of  the  Briinings 
electroscoi)e.  The  thread  of  the  small  lam])  and  the  thread  in  the  light 
carrier  should  be  carefully  standardized  so  that  new  lamps  will  fit  and 
burn.  If  this  detail  is  attended  to,  the  small  lam]»s  give  almost 
no  trouble.  The  great  a(h'antage  of  the  self-liglited  tul)e  is  that  its 
handle  is  not  complicated  and  so  at  times  in  the  way,  and  tliat  the  eye 
of  the  observer  has  the  fi;ll  diameter  of  the  tube  to  look  and  work 
through  from  the  beginning  of  the  tube  to  its  end.  This  reduces  the 
eye  sti*ain — the  physician's  eyes  are  his  capital. 

The  advaiitnt;-!'  of  illiiniiiiating  the  tuhe  l)y  reflecting  light  throngh 
it  is  that  the  illumination  is  uevei-  lost  in  the  ])i'esence  of  secretions.  A 
candid  observei'  nnist  admit,  however,  that  it  is  more  tiring  to  look 
through  tlie  nai'row  slit  in  the  mirroi'  of  the  electrosco))e  than  it  is  to 
look  through  tlie  full  lumen  of  the  self-lighted  tube.  The  author  has 
read  the  discussions  which  deal  with  the  question  of  lighting  from  the 
standpoint  of  optics,  but  has  settled  the  question  for  himself  at  the 
examining  table.  The  beginner  in  ])ronchoscopy  is  advised  to  do  the 
same. 

The  Jackson  Tubular  Speculum. — The  Jackson  tubular  spt'culum 
is  shown  in  Fig.  ll."!.  This  si)eculum  is  made  in  two  sizes,  tlie  larger 
for  adults  and  the  smaller  one  for  inraiits  and  children.  The  cut 
makes  detailed  descrijttion  of  the  instrument  unnecessary. 

Johnston  has  modified  the  Jackson  speculum  by  making  the  handle 
detachable. 

The  Briinings  electroscope  is  shown  in  Fig.  140.  It  is  inade  in  at 
least  three  patterns.  The  author  has  found  it  necessary  to  provide 
himself  so  far  with  l)nt  one  pattern. 

The  Briinings  Elong-ating  Bronchoscope. — The  main  tube  is  a  long 
tubular  speculum.  This  is  used  to  examine  the  trachea  as  far  as  the 
bifurcation  and  the  esophagus  as  far  as  the  arch  of  the  aorta.    For  ex- 


T,.\nVX(;ilSC()l>V.    HKONl'IKlSCnl'V.    KSorilAcidSCOPV.    KTC. 


l!i: 


aiiiinatioii  lieydiul  tlioso  dopllis  a  siiialltT  tiilic  is  littcd  into  tlir  larjicr 
one  and  carried  down  and  l)eyond  it  liy  means  iif  a  stont  spring.     By 
this  device  tlie  lulu-  can  lie  len,i?tliened  at   will.     'I'liis  form  of  tnlie  is 
especially  ii.-eliil  in  examinalions  jjerformed  iimlei-  lural  aiie^l  hcsia. 
The   Briinings   Elongating-   Forceps. — Briinin,ii;s   has   ajiiilied    the 


jninciple  of  the  elomiatiiiu-  tiilie  t( 
of  forceps  is  very  usefnl  espe- 
cially as  the  shaft  is  fitted  with 
tijis  adapted  for  all  necessaiy  ma- 
nipulations. The  operator  should 
sni)i>ly  himself  with  a  lilieral  as- 
sortment. It  is  vital  to  have  a 
fjood  tip  for  iiraspinu'.  a  tip  niaile 
in  the  form  of  a  puueli,  and  a  tip 
of  the  ))roper  form  for  sei/.iiiu' 
heans  and  other  see<ls.  Special 
cases  call  for  special  iiist  niments. 
Batteries. — The  lainp  in  llu' 
Jackson  speculum  and  hroncho- 
scope  is  most  conveniently  Tmht- 
ed  by  a  current  obtained  from  dry 
cells.  Jackson  em])loys  a  doui)le 
battery.  After  considerable  ex- 
pei'imentiiiii'  the  wi'lter  has  found 
four  di-y  cells  controlled  li\  a 
small  rheostat  the  most  portalile. 
the  easiest  to  rem'W  and  alto- 
.iretluM-  the  most  satisfactory. 
(V\iX.  141.)  There  are  maii\' 
foi'iiis  of  rheostats  with  wliicli 
the  ordinary  st  reet  cui-rent  can  lie 
used.  These,  howcvcr.  are  too 
bulky  to  carry  al)ont.  The  liuht 
in  liriininu's'  electroscope  calls 
for  a  reasonalil\  powerful  wall 
rheostat,  such  as  is  found  in  the 
('(luipmeiit  of  the  ordinar\  oper- 
atiiii,'  idom. 

Aspirator  for  Removing  Se- 
cretions.—The  Jackson  broiu-ho- 
sco]K'  has  in  addition  to  the  sec- 


liis  forcejjs.     (Fi.u;.  14S.)     This  form 


Klu'ostat   ami   battery. 

Tlie  uutlior  lia.s  found  tlic  small  ilotaclioil 
rhec-itat  aiiil  four  dry  cells  united  as  a  unit 
the  simplest  way  of  obtaininj;  tlie  curient 
to  run  tlie  lam|)  of  tlie  l)roneliosco|)e.  The 
batteries  are  easily  olitained  and  reailily  eon- 
nected  with  the  rheostat.  Batteries  that  eoiiie 
in  cji.ses  often  have  to  be  sent  to  speei.-il  deal- 
ers for  refilling,  so  that  there  is  delay  in 
getting  them. 

In  carrying  a  battery  of  this  kind  it  is  nec- 
essary to  see  that  it  does  not  beconi(>  short- 
circuited  ill  the  instrument  bag  and  its  power 
exh.austed.  An  iimperemeter  is  used  to  test 
the  battery  before  it  i.s  used.  The  physician 
always  knows  whether  or  not  there  is  suiricient 
current. 


194 


(ii'KUATivK  sri;i;Kiiv  ok  thk  xosk.  TiiiidAr,  .vxn  km\. 


oiidary  lulic  wliicli  carric-^  the  linlit  a  si'i-niid  auxiliary  tiiln'  for  tlit' 
ri'iniixal  of  sccrctidiis.  A  iiaml  hull)  may  he  used  attaclicil  in  tin'  siu/- 
tinu  ;iiln'  (ir  ail  ai)i)aratus  such  as  is  t'iii})lo\('(l  Inr  rcui(i\iiii;-  lluid  frdni 
the  clii'st,  or  best  of  all  an  aspirator  run  by  clccl  ricity.  Small  amounts 
of  secretion  are  rcmoxcd  by  folded  nair/.c  swabs.  The  ('oolid,ii,'o  cotton 
carrier  is  excellent  foi-  this  iiurjiose.  (  Fi^-  l-fl'.)  In  direct  examina- 
tions of  the  larynx,  lon.i;'  angular    forceps,   the   blades   of   which   lock 


Fig.  142. 
Coolidae  's  cotton  paiiier. 


Fig.   14.-!. 

Aiii;ul;n-  forceps  for  use  xvitli  tlio  afljustalile  specu- 
I'lni.  The  forceps  are  employed  chiefly  for  sponging  with 
cotton  or  gauze,  Init  are  extremely  useful  for  e.xtracting 
foreign  bodies  from  tlie  nioutli  of  tlie  esophagus.  They 
ca7i  also  be  used  for  removing  intubation  tnbes.  The 
■author  uses  this  instrument  for  cocainizing  the  pharynx 
and  larynx  preliminary  to  direct  examination  of  the  larynx, 
or  esopiiagoseopy  or  bronchoscopy. 


C5= 


Fig.  144. 

Mosher's  alligator  forceps.  These  forcejis  have  locking  han- 
dles so  that  tlie  blades  hold  firmly  whatever  they  grasp.  They 
are  made  in  two  lengths.  The  shorter  length  is  useful  for  direct 
work  upon  the  larynx,  and  the  longer  (14  inches)  is  very  con- 
venient for  carrying  cotton  for  swabbing  out  the  shorter  esoph- 
agoscope.  It  is  mucli  easier  to  load  this  forceps  with  cotton 
tli.'ni  the  usual  cotton  carrier. 


(P"'i^-.  143),  are  useful  for  removing  the  thick  secretions  in  the  pharpix. 
Long  alligator  forceps  (Fig.  144),  also  Avith  handles  which  lock,  are  a 
luxury  when  short  tubes  are  used  because  it  is  very  easy  to  replace  the 
sM-al)s.     (Figs.  145  and  146.) 

Acquiring  Skill. — Briinings  in  his  course  to  students  drills  the  men 
in  the  extraction  of  foreign  bodies  ]ilaced  in  a  rnliber  mannikiu  of  the 
respiratory  tract.  Practice  of  this  kind  is  very  valuable.  By  it  the 
))eginner  learns  to  see,  and  learns  the  Itest  wav  of  nsini;'  the  different 


T..\i;vNi;os((ii'v,  itr.oxciioscdpv.  KsoriiAcosrfU'v.  ktc 


1!).". 


kinds  i.f  forceps.  IT  Killi.iirs  iii:ninikiii  (  Ki.i;-.  147)  is  ii<»t  at  Imiid  iimcli 
llic  saiiif  kiii.l  iif  pracliri'  can  lie  ..litaiiied  if  a  furcifjii  luidy  is  placed 
in  a  ndilier  tube,  l-'urei^ii  hodii-s  may  l)e  placed  in  liie  air  passaiics  of 
narcotized  dous.  'I'lie  cadaver  >ised  for  lironclidscopy  <,dv('s  liotli  jirac- 
tice  in  reir.oviim'  foreign   liodies  ami   what    is  even  more  important,  a 


cs»c 


'i^—^^^^x 


Fig.  14o. 
Jackson's  tulio  fdicops.     B,  actual  size  of  liilie  and  jaws  of  forceps:  P 
and   K.   dilators   for   l)ronclioscopio   strictures,    wliich   can   lie   used    in   con- 
nection with  Jackson '.t  tulie  forceps  liandle. 


Fig.  1-16. 
Coolidge's  forceps. 


knowledge  of  the  applied  ;niat(ini\  of  the  Iniuu-hia!  tree.  The  hest 
practice  of  all  is  afforded  hy  an  adidt  patient  wearinii'  a  traclh'otomy 
tnl)c  if  tlie  pliysician  is  fortunate  enouijli  to  find  such  a  patient  who  is 
willinii-  to  nviko  cajiital  of  liis  inlii'mity. 

If  the  jihysician  who  undertakes  Inimchoscopy  oi-  esophanDscojiy 
is  meclianical.  and,  in  addition,  has  or  will  ac(piire  an  elementary 
knowledge  of  applied  electricity,  many  dillicnlties  in  his  new  work  will 
he  easily  oveicome.  Jackson  is  fond  of  sayinJ,^  and  sayinu'  it  in  liis 
forcible  way,  that  the  extraction  of  forei.mi  bodies  is  ])-,irely  a  matter  of 
mechanical  skill,  inlmni  skill,  however,  can  be  offset  and  sometimes 
surpassnl  liy  tlh'  ~Kill   whirli  I'cmies  from   wiHinune-^  to  le;irn  and  at- 


196 


OPERATIVE   S;tkgERY   OF   THE   XOSE.   THROAT,   AXD   EAR. 


tciitioii  to  detail.  And  the  details  of  iiistnuuents  and  instrumentation 
in  bronchosco]jy  are  many.  Tlie  physician  who  is  not  willing  to  deal 
with  these  petty  details  is  happier  out  of  this  kind  of  work.  The  moral 
of  this  little  preachment  is — learn  your  instruments,  how  they  are 
made,  how  they  should  work,  and  how  they  aie  to  be  kept  in  order. 
"Gridley,  you  may  tire  when  ready."    You  must  be  Gridley. 


Fig.  147. 
Killian's    manikin   for   practir.ing    bronchoscopy   and    esophagoseopy. 


Direct  Laryng-oscopy  for  Diseased  Conditions. 

Malignant  Disease. — ^^lalignant  disease  often  calls  for  the  direct 
examination  of  tlie  Iar\mx  in  order  to  obtain  a  clear  view  of  the  growth, 
and  especially  to  secure  the  removal  of  a  satisfactory  specimen.  By  the 
use  of  a  good  punch  forceps  (Fig.  145)  this  can  be  taken  from  the  most 
favorable  place,  that  is,  from  the  margin  of  the  growth  so  that  the 
diseased  and  healthy  tissue  appear  side  by  side.  In  small  growths 
direct  laryngoscopy  and  direct  instrumentation  should  not  be  depended 
uiHin  for  a  cure — the  larynx  should  be  opened  from  the  outside;  but  in 


T.Ain  XCllSCdlM  ,    lU'.dNCIIOSl'Ol'V,    KS(H'llA(i(ISC'()l'V,    KTC  ll'l 

advaiu't'il  and  iiioiKTalilc  niali^iiant  dist-aso  palliative  iHin'cdiins  like 
tlie  roiiioval  of  obstniftiiiii;  masses  aro  JustiliaMi'  and  arc  easily  e\ 
eeiited.      (Fi-s.   US  inn. ) 

Non-Malignant  Disease  of  the  Larynx.  Beni,nn  iie(i|i!asnis  of  the 
larynx  ulTer  a  wiilo  lield  Inr  ilic  eiii|il(iynK'iil  <if  direct  laryngoscopy. 
Chief  anionj;-  these  tumors  are  papillomata.  In  the  experience  of  the 
writer  the  removal  of  papilloniata  under  lue.-d  aih-tlievi;i  has  not  l)een 
successful.  Even  with  tiie  use  of  a  ufiieral  aiie-l  lid  ie  and  witli  the 
jiatieiit   lyiuii'  on  his  liaek   llie  procedure  is  not   always  a  calm  one  or 


Briiiiiiigs'   c!on<;;iiting   forceps. 


Tips   for   Briinings' 

forceps. 


Fij,'.     l.'iO. 
Expaiuling   tip 
fur    Briiiiinjis'    forceps 


fully  satisfactory.  Direct  laryn,L;(isciipy,  Iihwcmt,  is  liy  far  tiie  best 
method  of  conducting  the  i-eiii(i\al  of  tliese  luxuiiaut  and  recurring 
growths.  The  management  of  these  cases  adxdcated  l>y  Clai-k  is  the 
(me  followed  by  tlie  author.  The  child  i>  e\aiiiined  nuder  ctlii'r  by  the 
<lirect  method,  and  if  there  is  an  abuiulaut  growth  tiacheotomy  is  jjcr- 
formed.  Then  the  larynx  is  fi-eed  from  papillomata  by  using  appro- 
priate instruments  ihrongli  the  Jackson  speculum  or  the  open  sjiecu- 
liiiii.  Where  the  vestibule  of  the  larynx  is  nearly  choked  with  the 
.Lrrowtli  .Mn>|icr's  spiral  win-  fniccps  (Fig.  ].")!  i  will  i|nickly  i'cnio\-e  a 
large  amount  and  allnw  tlic  rcmaiiiini;'  uuissi.s:  i,,  I,,'  di.alt  wiih  leisui'elv 


198 


OPKUATIVK    SritdlCKV    OI'    'I'l  i  K    XOSK.    THIIOA'J',    AXU    EAR. 


and  with  tlic  sanio  iiistniniciit.  The  sjiiiai  wire  rnrccps  cniiii's  up  with 
l)a]>ili()inata  l)otwoeii  the  \arii>ns  wiix's  like  a  lish  iirt  lilicil  with 
tish.  It  is  iinpoitaut  in  rcni()\ing'  i)apiik)iiiata  tn  wniiiid  the  normal 
mucous  mcmhranc  as  Htlic  as  jiossihle  Ijccansc  cat'ii  ahiasion  is  ahuost 
sure  to  lun'c  the  growtli  transjilantod  uijon  it.  When  the  jiapillnma 
is  ])laeod  well  forward   on  the  cord  or  in  the  anterior  eommissurc  it 


Fig.  loK 
Mosher 's  spiral   wire   forceps   for  removing   jiapilloma   of  llic   laryn.v. 


is  often  very  hard  to  expose  even  nnder  general  anesthesia.  In  such 
cases  the  triangular  guillotine  tuhe  is  useful  for  securing  it.  (Fig.  152.) 
It  has  been  the  experience  of  Clark  that  after  a  child  has  Avorn  the 
traclieotomy  tube  a  year  or  more  the  papillomata  shrink  markedly 
and  in  time  disappear.    At  appropriate  intervals  the  child  is  etherized 


Fig.  1.52. 
Moslier's  triangular  fenestrated  tuVje.  Used  for  the  removal  of  pedun- 
culated growths  from  the  vocal  cords.  It  is  especially  useful  when  the 
grow'th  springs  from  the  anterior  commissure.  In  use  the  growth  falls 
through  the  window  of  the  tuhe  and  is  cut  off  by  forcing  hcimc  tlie  iilunger 
which  has  a  cutting  edge  and  acts  as  a  guillotine. 


again  aiul  tlie  remaining  growths  thinned  out  ov  eradicated.  Some 
operators  like  Jackson  do  not  i)ractice  tracheotomy  in  cases  of  papil- 
lomata but  follow  the  growths  through  the  cords  into  the  trachea  even 
without  the  safeguard  of  this  jjrocedui-e.  An  emergency  tracheotomy, 
hoAvever,  may  be  called  for  at  any  moment.  Tliis  operation  can  l)e 
taken  out  of  the  emergency  class  and  performed  at  tlie  leisure  of  the 
opei-ator  if  the  patient  is  given  air  b}^  intubing  the  larynx  and  trachea 
with  a  small  bronchoscope.  The  author  has  made  for  this  purpose  the 
small  iiistrum(Mit  shown  in  Fig.  l.")!^  which   lie  carries  with  his  trache- 


i,.\i;vx(;iis((>rv.  r.iKiNriiuscni'v.  ksoi'iiacoscoi'v.  ktc.  '!'!' 

(ttoiiiy  si't.  It  is  >iii;ill  ciKiti.uli  1i>  pMss  into  ■■my  l;ir\iis  jiikI  loii^  i'ii()ii;;li 
to  uii  well  down  tlic  traclii-ii.  It  i>  lilt.'. I  willi  :i  pliiii.^vr  .-o  (liat  viTV 
littlo  oxposun'  of  tlu'  larynx  is  lu'ct-ssaiv  lor  it.-  c|ui(k  Inl  rocjuctioii. 
Tliorc  arc  bivathiiij;'  lioh's  on  tlic  sides  wc-m  tlu'  lowii  ciid.  To  li,i\<' 
this  sinipit'  iiisti'iiiiicut  .•il\\;i\>  :i1  liaiid  i>  a  i^ifal  roiiiforl.  Il  cin  !"■ 
ust'd  willi  adidt.-  a>  well  a>  willi  rliildii'ii. 

Harris  has  lately  iv|ioiti'ii  thf  di-a|i|"'aiaii<'>'  of  a  papiihuiia  iiiidi'i 
radium. 

Other  lM'ni,iiii  neoplasms  occui-.  and  tlicsc.  Just  as  iia|)illomata.  arc 
Ix'st  d(>alt  with  liy  diifi-t  laryngoscopy,  .\mouj;  tiicsc  aic  liliromata. 
li|)oniata.  (•y>1>  and  cdi-matous  polyjii.  Sinjicrs'  nodes  mi^lit  he 
treated  liv  this  method  sho\dil  removal  he- advisahie. 


Fig.  lo?.. 
Small  l)roiiihosi'0]>(>  for  eiiiergoncy  iiitiiluitioii  wlii'li  llio  author  ahviiy~ 
carries  in  his  kit.  By  means  of  it  iMtul)atioii  eaa  be  quiel<ly  iierforiiieil. 
The  in.stniment  i.s  small  eiuiufih  for  a  iliilil's  larynx.  By  using  an  instru- 
ment of  this  kind  many  emorgeney  traelieotomies  can  lie  avoideil.  If  a 
tracheotomy  becomes  necessary,  the  procedure  is  made  simple  and  easy,  be 
cause  the  patient  breathes  through  the  bronchoscope  and  the  o|)ening  hi 
the  trachea  can  iie  done  calmly  and  without  liurri-.  In  nmny  instance 
familiarity  with  such  a  jireliminary  intubaliou  would  be  a  great  help  to  the 
general  surgeon. 


Tuberculo.sis  of  the  Larynx.— W  hen  tuhereul(-sis  of  the  larynx 
ealls   I'oi-  -uruieal   tre;itmeiit    direct   operatiu.n'  is  rjost   satisfactory. 

Inflammatory  Diseases.  In  infectious  of  tlte  pharynx  accompa- 
nied by  edema  or  abscess  the  patient  can  he  reliexcd  hy  direct  laryu- 
i:-oseo|)y  and  direct  ti'eatmeiit   and   man\    a   traelieot(nny   axerted. 

Malformations  of  the  Larynx,  Congenital  and  Acquired. — Counen- 
ital  \veh>  (if  the  larynx  are  easv  to  make  out  and  to  treat  hy  tlic  direct 
nietiiod.  An  appropriate  -peculiini  and  a  joni;-  lar\ni;i'al  knife  are  tiu" 
Old)    inslrunient>  usnaliy  needed. 

Al'tei-  diphthci-ia.  especiall\  when  it  has  heen  necessary  to  iutube 
often,  the  cords  nia\  Liine  toLiether  for  a  certain  ]iart  of  their  lenutii. 
(Jpiionilly  the  anterior  third  or  two  thirds  of  the  inner  surfaces  of  thi> 
cords  adhere.  Sucii  teases  can  lie  manaiicd  by  prolonged  intubation 
with  lar<!:c  tubes  of  the  Kodyers  pattern.  'I'he  eorils  must  be  first  sepa- 
rated. Tills  is  done  eitlier  with  an  Otis  urethrotome  or  with  the  laryu- 
ji'eal  knife.  Then  the  aperture  of  the  ulottis  and  tlie  reijion  la-low,  for 
tile  subjilotfic  porti<ni  of  tiie  lar\  ii\  i>  narrowed  also,  is  strctelied  with 

the  dilatin.a:  meclianism   of  tiie   nnthrotoi r   belter  with   a   dilator 

•  •nnstnieted  on  tlie  pattern  ot'  Kollman.  .\s  the  liodiicis  tube  is  con- 
ical and  tends  to  slip  ont  of  tln'  lar>n\  il  i>  retained  liy  a  (das)>  inserted 


200 


OPKKATIVK    SriKlEllV    OK    T 1 1 K    XdSK,    Tlll'.OAT,    AND   EAR. 


aiiil  \v(irii  tliroiiLili  ;i  pcriiiaiiciit  tnu'licutoiiiN'  woiiinl.  For  (lihitiiii;-  the 
cavit)  of  llic  larynx  iiialc  urotliral  sounds  may  l)c  passed  tlirouiiii  flic 
trat'lieoloiuy  wound  ujiward  into  tliu  larynx.  Naturally  the  opei-ative 
procedures  are  earried  out  hy  direct  hnyn.i>oseopy.  The  insertion  of 
Ihc  tnlie  is  most  conveniently  perform(M|  h\  dii-cct  intuhatiou.  In  this 
country  AVilson  was  the  first  to  bring  direct  intubation  before  the  pro- 
fession. Tile  autlioi'  has  devised  a  set  of  instruments  for  handling  the 
tubes.  Tile  authoi-  also  has  used  direct  inspection  a  few  times  for  the 
detection  of  laryngeal  di]:)htlieria,  the  removal  of  loose  membrane  and 
inune<liate  intubation.  Direct  inspection  generally  makes  the  waiting 
for  tlie  microscopic  re]jort  of  a  culture  unnecessai'V.  It  is  a  great  satis- 
faction to  look  down  an<i  to  see  the  membrane  and  to  take  the  case  out 
of  the  emergency  class  then  and  there  by  intubation. 

Retrograde  Laryngoscopy. 

Eetrograde  laryngosco])y  is  the  name  given  to  the  examination  of 
the  larynx  from  below  by  means  of  a  tracheoscope  introduced  through 
a  ti-acheotomy  wound.  This  method  may  give  valuable  inforination. 
The  tracheoscope  should  be  5  nun.  in  diameter  and  14  cm.  long  for  a 
child,  and  8  mm.  Avide  and  "20  cm.  in  length  for  an  adult.     (Jackson.) 

Tracheobronchoscopy  in  Diseases  of  the  Trachea  and  Bronchi. 

Diseases  of  the  trachea  and  the  bronchi  wiiich  call  for  broncho- 
scopy are  divided  into  stenotic  and  non-stenotic. 

Since  the  advent  of  bronchoscopy  many  cases  considered  as  nerv- 
ous cough  have  been  found  on  examination  by  tracheobronchoscopy 
to  be  due  to  visible  and  cui'able  lesions.  l)r()nchoscoi>y  was  given 
its  first  great  impetus  when  it  was  ])r()Ved  that  it  is  i)ossible  to  remove 
by  its  aid  foreign  bodies  lodged  in  the  trachea  and  bronchi.  This  field 
has  been  well  exploited.  In  tliis  country  at  least,  Imt  little  work  has 
been  done  with  it  in  the  \'arious  diseases  which  can  be  disclosed  and 
treated  by  it.  In  the  near  future  there  should  be  a  great  advance  in 
this  line.  For  the  fullest  knowledge  that  we  have  on  this  subject  the 
reader  is  referred  to  the  book  of  Von  Schroetter.  Ulcerations  near  the 
l)ifurcation  of  the  trachea  Avhich  were  causing  chronic  cough  have  been 
found  repeatedly  and  cured  by  applications. 

Chronic  catarrhal  inflammation  of  the  trachea  which  does  not 
yield  to  the  usual  forms  of  treatment  justifies  direct  examin.ation  and 
treatment. 

As  a  surgical  feat  which  as  yet  has  not  been  dn]>licated  many  times, 
but  which  may  at  any  moment  become  a  common  procedure,  the  finding 
of  pus  near  the  perijjhery  of  the  lung  may  be  mentioned.  ^Vbscess  of 
the  lung  due  to  a  foreign  liody  can  be  localized  by  the  lu-onchoscope 


I..\l;Y^'^i()s((ll'^ .   i;i;(i.\(  lMl.--((ll'^ .   i.xii'iiAiioxni'N .    i-.n 


L'dl 


;iiul  if  ihc  I'oroijrii  Ixxly  cjiiiiKtl  lie  sciMiivil  tliroiii^li  tin-  tiiln',  the  (iilif, 
til-  .1  luolio  i)asst'il  tlironn'li  it  can  lu'  iiscd  as  a  nuidc  to  liu'  surnt'im 

cutliim-   iVolu   tile  (illtsiilr. 

Stenosis  of  the  Trachea.  Xi'iL^lilHiriim-  (ir^ans  not  iiiri-ciiuciitly 
pivss  njiitn  the  traciicn  and  cause  il>  |i,iili;il  oci-lnsion.  Tho  tliyroid 
iiiaiid  is  a  TroiinLMit  olVcudiT.  As  a  nilr  it  I'lr-si's  liackward  and  sinct- 
ono  loho  is  .nonorally  nioir  ciilaiiicd  than  the  other  tlie  rt'sultin,i>'  nar- 
rowinn'  of  tho  trachi'a  oeenrs  in  tiie  anlen)|iostiTior  ilireetion  and 
soniewinit  hiterally.  AVhen  the  rctrotraclu'al  portion  of  tlic  uland  as 
well  as  the  anterior  part  eidariics  tlie  traehi'a  heeomes  a  narrow  o\al 
slit,  the  "s<'alil)ard"  traelu-a. 

It  lias  boon  dcnii'd  that  eiilarncinent  of  tiie  tliynms  could  |iro(hice 
<lillic'n!ty  in  Ijreatliinu',  the  so-called  thymic  astliina.  Jackson  reports 
a  strikinii  case  in  which  the  condition  was  i>resent.  Wlu-n  the  case  was 
sci'ii  it  demanded  an  immediate  tracheotomy.  This  did  not  relieve  tlic 
dysjmca.  The  jiassaiic  of  the  traclieoseoi)e  showed  that  the  trachea 
helow  tlie  incision  was  Hatteiii'd  almost  to  complete  closure  frnm  before 
liackward,  Imt  the  insertion  of  a  huiv;  tracheotomy  tulie  linally  ndiexcd 
this  dys|)iiea  and  then  the  u'land  was  i-emoved,  llie  case  result in.i;-  in  a 
cure.  Tuliercular  ^laiid-.  csjiecially  those  at  the  liifiircation  of  the 
trachea,  maliii'iiaiit  disea.se  of  the  cso|)haf;ns  or  of  tlie  mediastinum, 
and  aneurism  often  narrow  the  lumen  of  the  tracliea  or  ot"  the  jirimary 
hronclii.  Tli"  diauiiosis  of  these  eoiidilions  may  be  conlirmed  or  estab- 
lished by  broncho.scopy. 

Jacksou  n-ives  the  followiii.n-  table  of  diseases  of  the  walls  of  the 
tracliea  and  the  liroiichi  whicii  canse  stenosis: 

1.  ^laliiiiiant   iieojilasms. 

2.  Benign  neoplasms. 

3.  Specilic  inflammations. 

(a)  Syphilis. 

(b)  Tuberculosis. 

(c)  Glanders. 

(d)  Typlioid  fever. 

(e)  Diphtheria. 

4.  Tiiflamniations. 

(a)  "Catarrhal." 

(b)  Trritative. 

(c)  Traumatic, 
id)  ()perali\e. 

(c)      I'ost-oj)erative. 
').     Post-iiillammator)'  conditions  as  cicatrices  .-iiiil  atlln'sioiis. 
(i.     \'asomo1or  dis1urliaiice>.  anuionenrot ic  edeiiia. 


202  OPERATIVE   SURGERY   OF   THE   NOSE,   THROAT,   AND   EAR. 

IJonign  neoplasms  are  not  frequent  but  when  they  are  ]3resent  tliey 
arc  well  adapted  for  removal  through  the  bronchoscope.  In  asthma 
sensitive  areas  have  been  found  in  the  ti'achea  and  bronchi  ;ind  appli- 
cations made  to  them  gave  relief.  Syphilis  is  the  most  frequent  cause 
of  stenosis.  Next  come  the  narrowings  caused  by  the  healed  ulcers  of 
diphtheria  or  of  typhoid  fever.  Stricture  of  the  lironchi  from  similar 
causes  is  occasionally  seen. 

Treatment. — The  treatment  of  stricture  of  the  larynx  by  prolonged 
intubation  has  been  described.  Strictures  of  the  cervical  portion  of  the 
trachea  associated  with  loss  of  the  cartilaginous  rings  are  probably 
best  treated  by  plastic  surgerj^  Avhicli  aims  at  holding  the  trachea  open 
by  the  transplantation  of  some  rigid  material.  The  success  of  the 
transplantation  of  cartilage  for  the  correction  of  nasal  deformity  may 
open  up  a  method  of  dealing  with  these  cases  of  tracheal  stenosis  com- 
liinod  with  loss  of  cartilage. 

The  treatment  of  low  seated  strictures  of  the  trachea  and  of  stric- 
tures of  the  bronchi  is  carried  on  along  the  same  general  lines  as  those 
employed  for  the  treatment  of  strictures  higher  up,  that  is,  the  stric- 
ture is  first  dilated  and  then  held  open  by  intubation.  Such  strictures 
call  for  treatment  because  wlien  they  are  small  they  interfere  with 
breathing  and  expose  the  lungs  to  infection  from  the  retention  of  in- 
fected secretions.  Von  Seliroetter,  who  has  carried  on  extensive  in- 
vestigations in  these  cases,  first  dilates  the  stricture  with  a  sponge 
tent  and  then  inserts  a  metallic  tube  so  made  that  it  is  readily  retained. 
It  would  seem  that  a  mechanical  dilator  Avould  accom]")lish  the  dilatation 
more  speedily  than  the  tent. 

THE  REMOVAL  OF  FOREIGN  BODIES  FROM  THE  LARYNX, 
TRACHEA  AND  THE  BRONCHI. 

Foreign  Bodies  in  the  Larynx. 

Foreign  bodies  lodged  in  the  larynx  in  most  cases  are  either 
coughed  up  after  the  initial  spasm  of  dyspnea  caused  by  them  or  drop 
into  the  trachea  or  the  bronchi.  Occasionally  the  foreign  body  is 
loosened  by  the  coughing  and  strangling  and  enters  the  esophagus  and 
is  swallowed.  Sometimes  the  foreign  body  becomes  impacted  in  the 
larynx  and  if  it  is  large  enough  it  speedily  suffocates  the  patient.  Now 
and  then  the  foreign  body  may  be  small  enough  like  a  piece  of  egg  shell 
to  remain  in  the  larynx,  or  it  may  be  of  the  right  shape  like  a  button 
or  a  coin  to  lodge  in  the  ventricles.  Examples  of  cases  of  l)oth  kinds 
are  found  in  the  literature.  When  snch  cases  jn-esent  themselves  direct 
examination  combined  with  the  use  of  appropriate  instruments  is  the 
best  method  of  removing  the  offending  foreign  body. 


I,Ai;VX(i(>S((tl'V,    mtOXCllOSCDPY,    KSOIMIACdSCOl'V.    KTC.  20.') 

The  Removal  of  Foreign  Bodies  from  the  Trachea  and  the  Bronchi. 

I'litil  thi'  ailxiiit  (if  traehi'iiscu|)y  and  liinni'liDSi-oiiy  tlie  ifiiKival 
of  a  foroiiin  Ixidy  rrnm  tlit'  traelu'a  was  aeconiijlishcd  liy  ])ei-f(>rniiii.t; 
Irachi'otoiny.  WIumi  a  loose  hody  like  a  si'('(l  was  playinu;  np  and  down 
ihf  li'ai'hca  seeivin.y,-  to  escape  it  was  often  lilown  violently  (uit  of  the 
wonnil  liy  llie  first  spasmodic  expiration  caused  iiy  eiiterinji:  the  tra- 
chea. Such  an  onteonu'  w.i-;  drauialic  and  s;ilisfactory.  If.  however, 
llic  foreii^ii  liody  was  not  free  in  Ihe  liadiea  hut  wa>  impacted  or  was 
of  a  <lilferent  nature  from  a  seetl,  llie  old  practice  was  to  intrudnce  for- 
ceps hliiully  and  to  fish  for  it.  Many  snceessfnl  extractions  Inivc  hcen 
jjcrfornu'd  in  this  manner.  Many  times,  however.  ;iud  the  records  arc 
woefully  incomplete  as  to  liow  many  times,  the  attempt  at  Idiml  extrac- 
tiou  has  failed  ami  lia>  e;iii>ed  the  death  of  tiie  p.aliiMil. 

It  was  a  natural  and  great  adxance  in  tin.'  treatment  of  these  cases 
when,  instead  of  the  hlind  groping  after  foreign  bodies  in  the  trachea, 
the  I'hysician  lieiian  to  woi-k  hy  -ii;ht.  Coolidge  was  th(>  first  to  chi  this 
in  Ami'rica,  in  l^l'lf  l'>y  usinn' a  female  nrethroscoin'  lu'  located  and  re- 
moved a  piece  of  a  tracheotomy  tuhe  which  had  become  detaehetl  and 
had  fallen  into  tlii'  trachea.  Killian  was  the  first  to  demonstrate  the 
feasibility  of  i-emoving  a  foreign  body  from  the  bronchus  by  nu'ans  of 
a    tube    ])assed    between    the    vocal    cords.      Killian    dt'vised    and    first 

prjieticeil    U)iper   1  UolU'l  loscopy ,    later   lie   de\elo|ied    loWel'   hroncllOSCOpV. 

lOinhorn  in  I'.Hil'  di'\ise(|  an  e>npliai;(i-cope  jiaxiii^'  an  auxiliary  tnbe  in 
the  wall  of  the  main  tulie.  In  tlie  secoiidarv  tulu'  ;i  light  caiTier  was 
iuseited  tliniULjh  which  twci  \\ire>  lan  to  a  >m;dl  electric  lamp  on  the 
end  of  tlie  can-iei'.  'I'wii  year,-  later  .l;icks(Ui  iisi^d  tin'  mechanism  of 
I'^inhorn  on  the  Killian  tubes  ami  ,-idded  a  second  auxiliary  tube  for 
drainage  ]iurpn>es.  Later  the  >ame  investigator  lengthened  the  hron- 
chox-iipi'  and  used  it  for  exploring  the  stomach,  lie  demonstrated  the 
fea-iliility  of  iutroduciug  a  straight  tube  into  the  slomaeh  and  taught 
the  medical  profession  throULili  liis  hrilliaut  eases  the  \alue  of  the  |iro- 

eedui-e. 

The  Choice  of  the  Upper  or  the  Lower  Route.     Kxperience  has 

|ini\e(|  th.-it  hiucr  lunueli(i>ciipy  i>  >arer  ami  easier  than  up|ier  bi-ou- 
cllo>ci]py.  It  is  by  all  odds  the  safer  JUdcedure  for  the  beginner,  lu 
infants  and  children  nn<ler  tliice  years  of  age  it  is  the  o|)eralion  of 
choice.  I''.veu  with  oldei'  cliildicu  u]i  to  the  age  of  scNcn  or  eight,  if 
theie  i>  a  loose  foicigu  hod)'  wliieii  liv  its  \iolent  excursions  up  and 
down  the  trachea  has  cau-e<l  tiauma  to  tln'  lower  part  of  ti:c  lai'ynx, 
or  if  the  I'orm  of  the  foreign  hody  i-  >ueh  that  it  is  impacted,  for  ex- 
ample, a  beau  or  a  pin,  lower  iironchoscopy  is  surer  and  safi-i-.     If  the 


204  OPERATIVE    SnUiERY    OF   THE    XOSE.    THROAT.    AXn    EAR. 

()]ierator  is  skilleil,  upper  bronchoscopy  may  l>c  tried  with  children 
over  three  years  ohl.  Tiistanees  of  success  by  tliis  niethud  are  iiuil- 
tiplying.  I'nh^'ss  the  ]ir(ice(bu'e  is  soon  successi'nl.  ho\\e\'ei',  it  sliouhl 
l)e  abandoned  for  tiie  lowi'r  route.  It  is  not  so  nuich  the  increased 
leniith  of  tubes  required  for  n])])er  l)ronchoscopy,  Avhieh  makes  it 
less  advisabh^  in  many  cases  tlian  h)\ver  bronchosco))y — because  the 
self -lighted  tulie  carries  its  light  at  the  end  and  ineicase  of  length  is 
not  a  serious  factor — as  it  is  the  reaction  of  the  larynx  to  the  manipu- 
lations and  the  danger  of  cardiac  arrest.  (Crile.)  The  latter  danger 
can  be  obviated  or  minimized  Ijy  the  use  of  atropin.  Killian  has  col- 
lected nineteen  cases  in  -which  after  vTi)]ier  bronchoscopy  an  emergency 
ti-acheotomy  was  reipiired.  The  gist  of  the  matter  seems  to  be  that  in 
the  performance  of  upper  l)ronchoscopy,  a  tracheotomy  nuiy  at  any 
moment  be  called  fcu'.  Even  after  the  successful  outcome  of  the  pro- 
cedure the  same  holds  true.  With  infants  and  young  children  lower 
bronchoscopy  is  preferable.  In  a  child  of  any  age  it  is  not  good  prac- 
tice to  ])ersist  in  upper  bronchoscopy  unless  it  is  soon  successful. 

Indications. — Tracheobronchosco])y  is  called  for  in  any  case  in 
which  the  presence  of  a  foreign  body  is  suspected.  The  dangers  of  the 
yjrocedure  are  so  slight  that  even  when  tlie  presence  of  the  foreign 
body  is  not  sure  an  exploratory  hronchoseo^jy  is  indicated.  This  is 
especiallj'  true  in  the  case  of  children.  The  only  contraindication  to 
bronchoscopy  is  the  presence  of  serious  organic  or  systemic  disease. 

Dangers. — The  chief  danger  in  bronchoscopy  occurs  in  the  iise  of 
the  ui)i)er  rcnite.  This  danger,  as  has  just  been  pointed  out,  arises 
from  edema  of  the  larynx  or  from  reflex  cardiac  arrest.  Ingals  has 
reported  two  cases  of  death,  one  three,  and  one  six  hours  after  the  suc- 
cessful removal  of  a  fiu'eign  body.  These  unexplained  cases  may  have 
been  due  Avholly  or  in  part  to  the  second  of  the  dangers  just  mentioned. 
Apart  from  these  two  dangers  the  most  common  one  is  septic  pneu- 
monia, from  the  trauma  occurring  during  the  mani]mlations  of  extrac- 
tion. Another  danger  and  nue  wliich  can  be  easily  avoided  is  (hat  of 
delaying  the  performance  of  tracheotomy  when  the  ])atient  Itegins  to 
show  signs  Avhich  call  for  it. 

The  Danger  from  Leaving  the  Foreign  Body  Alone. — The  dangers 
to  which  the  jiatient  is  exposed  hy  lea\ing  a  foreign  body  in  place  are 
vastly  greater  than  the  danger  to  which  he  is  exposed  by  the  perform- 
ance of  bi'onchoscopy  at  the  hands  of  a  man  ])racticed  in  tlie  art.  The 
great  danger  incurred  by  a  patient  with  a  foreign  liody  in  the  lungs  is 
pneumonia,  or  abscess  and  gangrene  of  the  hmg.  In  most  instances 
either  complication  is  fatal.  There  are  many  cases  reported  in  the 
literature  of  foreign  bodies  which  have  i-eniained  in  tlu'  lungs  a  long 


i..\i;vN(;iisc()i'v.  niioNciidsroi'v.  Ksni'iiAnoscdrY.  I'/ic.  -H") 

liiiu'  u  host'  ini'sriUT  \\;is  Unowii  oi'  uiikimw  ii,  .iinl  w  liicli  liaxc  liocii 
filially  i-ouiihod  out.  But,  .judiiiiiy  even  rimii  the  iiicniiipli'ti'  litoraturf 
ot"  till'  rases  of  tlic   ()|i|)nsitc   natuii'.   it    i>   I'miiitl    tliat    siirh    furliinati^ 

toriuinatioUS    are    rare.       Sllnuld     the     piiticllt     rx-apr    >c|i|ie     |>lli'iillhilii;i 

ami  llic  I'lU'eiuii  lindy  ii'iiiaiii  in  llic  luims,  lie  is  r\|Mi>cil  t(i  tiilierciilar 
iiil'iTlidii  iali'i'.  Killian  is  aiillhnily  I'm  the  stalniiriii  liiat  such  eases 
not  iiit"re(jiieiitly  leniiiiiate  in  this  iiiaiiiier.  It  should  lie  said  in  fair- 
ness, however,  that  soiiu'tiiiies  the  liiiiiis  will  tolerate  a  foreij^jn  hody 
for  a  loiiij-  tiiiic.  'i'lh'  aiitiior  lias  in  mind  a  ease  in  which  Coolidtje  re- 
moved a  wile  nail  w  hieh  had  lii'eii  in  the  rii;ht  him;  of  the  son  of  a  phy- 
sician i'or  seven  years.  The  synii»toms  were  only  an  occasional  coiifjli. 
Another  case  oceurs  to  the  writer.  This  patient  was  a  nurse.  For 
five  years  now  and  without  any  clixnmfoit  she  has  hail  a  metal  clasp 
pin  in  her  Inny.  The  attempt  to  remove  this  jiin  was  made  on  two  or 
more  occasions,  once  hy  Killian  ami  once  liy  Jackson. 

Till'  decree  of  danL;rr  wiiieh  aerompanies  the  remov'al  of  a  foreign 
liody  nalui'ally  \aiii'>  with  i1>  iiaturr.  shape  and  si/.e,  its  location  and 

the  e litidii  (if  thr  patii'nt.      luMindcil  ohji'cts  aiv  liahle  til  lit   a   h)-cm 

elms  ti,i;litl\'  and  to  shut  nlV  aii-  to  the  portion  of  juim-  supplied  liy  it. 
Therefore  they  are  mo>l  lialilc  to  cause  uaiiuii'iie  and  ahscess.  A 
pointed  object  like  a  pin  nr  ,i  n.iil  allows  air  to  jiass  hut  it  jirodnces 
tranma  by  its  excursions  in  the  respiratory  blast  or  prodnces  erosion 
by  lyiiiii'  lon.<>'  in  one  jiositioii.     Hither  condition  leads  to  infection. 

Iiioiijanic  substances  macerate  and  decay.  When  this  happens 
they  may  be  coiiuhed  out  unless  they  have  produced  a  fatal  pneumonia 
before  this  take  place.  Seeds  if  uncooked  do  not  macerate  but  swell 
on  alisnibini;-  moisture  and  liecome  firmly  fixed  in  position.  Peanut.s, 
in  this  c(nintry  at  least.  ha\'e  pro\-ed  to  be  vei-y  fatal  foreiun  bodies 
to  lodyc  in  tile  luniis.  The  attempt  at  reino\al  ortcii  crushes  thcni  -.wm] 
scatters  the  fragments  deep  in  the  tertiary  bidiichi. 

Koe  collected  1,417  cases  of  foreiun  liody  in  the  air  passa.u'cs.  Tn 
470  extraction  was  not  attempted,  and  over  4()tJ  died,  that  is,  the  nior 
tality  was  27  jier  cent.  This  is  to  be  comiiared  with  !I4  cases  of  ujiper 
and  lower  hniiichnscoijy  repoiteil  liy  .lack>oii  in  which  the  mortality 
was  3.2  per  cent.  If  a  foreif;ii  body  is  to  lie  eouL;hed  out  this  licuerally 
occurs  in  the  first  twenty-four  iiours.  .laidvson  sums  up  the  matter 
fairly  wlien  he  says  "we  do  full  justice  to  our  patients  wIumi  we  tell 
them  that  w  hile  a  foreign  body  may  be  coughed  up,  the  chances  of  this 
are  remote  and  it  is  very  dangerous  to  wait:  and  further,  the  dilliculty 
of  removal  increases  with  each  hour  that  the  body  is  allowed  to  re- 
main." 

Results.  <  lui  (if  ii4  eases  of  In'onchoscopy  the  foreign  body  was 
removeij   in  s.")  per  et'iit.      iJacksuii.) 


20G  OPEKATIVE    SntCERY    OF   TTTE    XOSE,    TTHiOAT,   AND   EAR. 

Symptoms. — Cough  is  the  most  constant  symptom  of  a  foi-oion 
body  ill  tin'  air  i)assages.  As  the  foreign  body  passes  the  larynx  tiie 
cougli  is  paroxysmal.  Later  at  every  attempt  of  the  air  passages  to 
expel  the  intruder  tlie  cough  is  again  paroxysmal.  Some  minutes  or 
hours  may  elapse  between  the  seizures.  After  a  time  the  cnugii  be- 
comes more  constant. 

Dyspnea  is  a  very  frequent  sym])tom.  It  is  usually  iiis])iratni-y 
but  it  may  occur  on  expiration.  The  dysiniea  is  worse  during  the  fits 
of  coughing  and  at  such  times  the  jiatient  may  become  unconscious.  It 
should  be  borne  in  mind  that  a  foreign  body  in  the  esophagus  may,  by 
pushing  forward  the  soft  trachea  of  a  child,  produce  dyspnea. 

The  temperature  is  usually  elevated.  This  might  be  taken  as  evi- 
dence in  the  doubtful  cases  against  the  presence  of  a  foreign  liody.  In 
late  cases  in  which  i>iieuiiioiiia  has  set  in  naturally  the  teinpcrature  is 
elevated. 

Chills  occur  when  an  aliscess  has  been  produced  about  the  foreign 
body. 

Hemoptysis  is  not  present  as  a  rule.  It  is  associated  with  the  aspi- 
ration of  sharp  substances. 

Pain  is  often  ijresent  but  it  is  generally  jioorly  localized. 

Diagnosis — The  fiuoroscope  is  not  reliable  in  locating  a  foreign 
body  unless  it  is  very  dense.  An  X-ray  plate  should  be  taken  in  all  cases 
and  interpreted  by  an  expert.  The  physician  who  is  not  accustomed  to 
reading  jilates  taken  of  the  lungs  is  very  liable  to  mistake  spots  of  cal- 
cification along  the  main  branches  of  the  bronchi  for  foreign  bodies. 
Unless  there  is  marked  dyspnea  it  sliould  be  the  routine  to  obtain  a 
radiograph. 

Metallic  substances  Avitli  the  exception  of  aluminum  show  well  in 
the  plate.  So  do  pebbles  and  objects  of  glass.  Bones  unless  they  come 
in  front  of  another  bone  like  a  vertelira  also  show  well.  Fish  bones 
come  out  poorly  in  the  ]ilate.  Vegetable  substances  with  the  exception 
of  some  kinds  of  wood,  do  not  cast  much  of  a  shadow.  The  same  is  true 
of  peanuts  and  chestnuts  Avitliout  their  shells.  It  is  difficult  to  obtain 
a  satisfactory  X-ray  of  a  young  child  unless  it  is  etherized.  Only  in 
the  case  of  a  metallic  foreign  body  when  the  plate  shows  nothing  is  it 
safe  to  permit  the  patient  to  go  without  an  examination.  Intermittent 
cough  and  dyspnea  not  to  be  explained  in  any  other  way  and  not  associ- 
ated Avith  fever  is  almost  diagnostic  of  the  presence  of  a  foreign  body. 

The  Physical  Signs. — The  physical  signs  are  of  value  in  determin- 
ing the  presence  of  a  foreign  body  in  the  air  passages  if  they  are  elicited 
and  interpreted  by  a  physician  who  ]iossesses  a  good  and  sufficient 
techiiic  ill  aiisciiltatioii  and  jicrcussioii.     The  ])hysical  signs  arc  relied 


LARYNGOSCOI^Y.    r.KOXCIlnscoPV,    KSorilACOSCOPY,    KTf.  120" 

\i])()ii  iiKisl  ill  tliiisi'  i-asi's  ill  wliicli  ii  pusitivc  X  liiy  (•.•iiiiiot  lie  m'imiiimI. 
The  followiiiu'  paraiirnplis  wliicli  licar  iipoii  the  piiysical  si.uiis  ami  liii'ir 
moaiiiiiii'  arc  alislradod  rroiii  .Tat-kson  for  wIkhh  llicy  were  writicii  liy 
Boyoo. 

Tn  tlio  oxaniiiiatidii  a  ilisliiiction  iiiiist  It  iiiadc  lii'twi-rii  tin'  siifiis 
due  111  llie  rnreiiiii  Imdv  and  tlmse  wliicli  lire  due  111  inll;iniiiia1iiry  ciiii- 
ditions  wliieli  soon  su])orveiie. 

A  foreisi"!!  body  which  is  ohst nietiini  a  linun-liiis  iiia>  lead  lo  aielec- 
tasis  of  the  luiiu,-.  If  so,  the  usual  si,<,'iis  are  present.  'J'liis  occurrenco, 
howovor,  is  not  as  froqiUMit  as  is  yeiierally  supposed.  The  most  coin- 
mon  findin.y  is  a  marked  Im-al  diininuliiin  nf  the  re.-piralnrv  iininnnr 
with  ]ires(>rvation  or  accent  iiat  inn  of  the  nnrnial  resoiianee.  This  may 
he  called  the  typical  ei  nidi  linn.  W  lien  a  I'nrei^n  hiid,v  jiartially  nlistructs 
a  hr(Uichus  it  may  ^ixe  rise  to  a  i)eculiar  dry  r;ile,  winch  is  easily  dilVer- 
cntiatcd  from  that  ;;iveii  hy  iiillaiiuiiator\  m  tiilieiciilar  thickeuiiius  of 
the  mucous  meiuhrancc.  These  dry  rales  are  limited  tn  ,i  deliiiite  ;irea 
and  occur  for  hours  at  a  time. 

Bronchitis  is  the  commonest  iiill;imm;iiiii-y  cnnditlnii  I'nllowinij  tho 
inhalation  of  a  foreiun  hod\.  The  secietinii.-  I'mm  thi>  arc  soon  <rif- 
fused  through  the  lungs  and  ^i\e  the  signs  of  a  dillnse  hroiiclutis.  Dif- 
fuse bronchitis  coming  on  suddenly,  and  esiiecially  il'  it  is  accompanied 
by  bloody  expc<-tnratinii.  is  ;i  most  umi-nal  cnnditinn  and  should  raise 
the  susjiicimi  of  the  presence  nj'  n  I'nreii^ii  Imdy.  Till'  ex])ectorati(ni  in 
foreign  body  cases  is  iisnall\  lilnndy  .iiid  lends  tn  hecoine  abundant, 
])urulent  and  fetid.  In  such  instances  only  the  history  and  a  careful 
examination  of  the  sjiutum  will  iiile  nnl  t  nlierculn^is.  If  a  Incalized 
abscess  is  jnT'sent  m  lnli;ir  pnenninnia,  the  sii^iis  nt'  tlie^e  cniidilinns  ;ire 
the  same  as  when   tile>-  are  imt    ;is-nei;ited   with  a   l'nreiL;ll  hndy.      Ill  one 

case  plural  elVusimi  resulted  linm  the  presence  of  a  foreign  body  and 
tli(>  ])atieiit  was  twice  tapped.     (  Inuals.) 

Tulierculosis  "without  bacilli  in  the  sputum, "'  |iarticularly  if  the 
<li-e;ise  is  located  near  the  liase  itt'  the  riuht  Innu',  unilateral  n]-  uuilob- 
nlar  bronchitis,  and  e-pecially  if  lieiiinrrliagic  nr  I'etid,  ateleciasis,  ab- 
scess or  gangrene,  lint  otlierwisi'  explainable,  should  raise  the  suspicion 
of  the  presence  of  a  Inreigu  body  in  the  air  passages. 

The  Location  of  fniei-n  Imdie-  x'jiries  witli  tile  si/.e  aiid  shape 
<'\'  the  objects,  lindies  of  some  size  usually  loili:e  at  the  bifurcation  of 
tho  traciiea  or  enter  the  right  main  hioiicliiis.  I'iiis  often  Iodide  at  ilie 
bifurcation,  one  half  the  jiiii  hein--  in  the  traciiea  and  the  other  half 
1>  im:'  in  a  )irim;ii\  hrnnchii-.  i  f'iu.  l."i  1.  i  I 'in-  and  nails.  hnwe\er.  iint 
infrei|nentl>-  fall  into  the  smaller  biniichi.  hi  ihe  e\|)erience  of  the 
autlmr  pins  and  nail.-  frei|iiently  Ind-e  in  the  inner  iirauch  of  the  bron- 


208 


(ii^ki;a'I'i\k  sriicKKV  of  tiik  xo,'^ 


TIlIldAT,    AMI    KAi;. 


e\\u^  t(i  the  iiil'cridi-  Icilu'  (if  the  ri.uhl  luiin'.    SatVty  ]iiiis.  if  tlicy  nw  uprii, 
<l(i  luil  u'cl  licvdiiil  tlic  traclica. 

The  Technic  of  Removing  Foreign  Bodies. — Tlu'  first  tliiiii;  to 
aecoinplish  is  to  bi'ing  the  I'di-cii;-!!  body  into  view.  Tln'  iiiaiiiimlatiiuis 
of  the  bronclioscope  which  are  necessary  to  accomplish  this  liave  been 
described.  After  locating  the  foreign  body  and  obtaining  a  good  view 
the  next  important  step  is  to  use  the  prop)er  instrument  for  seizing  it. 
^lany  a  case  has  resulted  in  disappointment  owing  to  the  fact  that  the 
physician  went  ahead  witliout  suitabk'  instruments      Tnlcss  tlie  case  is 


Fiii-.  154. 
I'iii    w  itli   oiass   head   in   Ici't    main    lironcluis 


desperate,  time  should  be  taken  to  procui'e  a  forcejis  with  a  tip  fitted  lo 
grasp  the  particular  object  dealt  with.  Beans  and  seeds  call  for  a 
special  tiji.  Pins  may  be  extracted  with  the  ordinary  forceps,  but  in 
case  the  pin  is  impacted  the  pnn  cutter  of  Casselbcrry  (Fig.  155)  is 
essential.  The  usual  In-onchoscope  has  lateral  openings  in  the  lower 
tliird  or  half  of  its  length  so  that  air  may  not  be  shut  off  from  the 
opposite  lung  (hiring  the  cNamination.  ^\'h('n  dealing  with  a  pin  these 
openings  should  not  come  to  the  end  of  tlu'  tube,  otherwise  the  pin  may 
be  caught  in  tln-m.  Open  safety  pins  are  best  extracted  with  a  closer 
(Briinings,  ]\loslier,  or  Hubbard). 


I..\i;VNf,()SinI'V.    liKONilKISCOl'V.    KSdI'l  lACIlSCOI'V,    KTC. 


Sol't.  iiliiililc  siil)sl;iiu'i's  like  fiililuT  call  I'nr  a  cnrkscicw  lilo'  in-t  i  ii 
iiiciit,  as  ill  tlic  case  ivporti'd  by  Kiflianlsoii. 

Tlif  liicatcst  ililliciilly  is  rduinl  in  tln'  i'\i  i-aci  imi  nl'  small  IhmIIcv 
<lci'|)|y  |ilaci'(l  ill  tile  lirniii-lii.  'I'licsc  arc  nl'lcii  iiiai'cialcd  or  inilicdilcd 
ill  swollen  mucosa,  in  worUiiiii'  in  the  snialicr  bronchi  and  mar  ihc 
)icii|ilicry  of  the  liiiiii-  the  physician  may  lind  it  ncccssai  \ ,  on  account 
of  jioor  liiilit  or  the  (liiniiiutive  foltl,  to  pass  tlio  forceps  bcyoml  tlic  tnl)c 
and  to  close  them  blindly,  liel'ore  this  maneuver  is  executed  a  mark  is 
placed  on  tlie  shaft  of  the  forceps  to  sln»\v  the  len.<rtli  of  the  tul)e. 

Hooks  of  various  shapes  are  usid'ul  to  jiass  beyond  a  foreiiiii  iiodv 
in  oi'der  to  jtrevent  the  forceps  Iroiii  pushing  it  dow  n  or  to  turn  the  for- 
eign l)ody  so  that  the  lilade>  of  tlic  foiccps  can  uiasp  ii.  The  hook  is 
passed  flat   until  beyond  the  object   and   then   liii-iie<l  and   bronuht    up. 

g-?-^        ^-^^ v..     S, 


Fig.    I.-).-). 
Cassclborry  ".s   ])in   lullpr. 


("are  is  rcipiiicd  not  to  catch  the  end  of  a  fully  curved  hook  in  the  o]>en 
iiii;-  of  a  lu-oiiclius. 

In  llic  casi'  of  hollow  foieimi  bmlies  expaiidin.n'  forceps  are  of 
service.  If  the  foicimi  body  i>  jod-cd  in  a  small  cavity  of  the  liim;-  it 
may  be  uecossai>  to  dilate  the  opeiiiu-  into  the  cavity  before  the  for 
eiii-ii  l)0(ly  will  come  into  view  and  peiiiiit  extraclioii.  Jackson  has 
ilevised  a  dilator  for  lliis  piii|io-.e. 

I'sually  secretion  is  seen  coming;'  <nit  of  the  i)roiichn>  in  which  the 
foi'ci.Hii  liody  is  lodiicil.  Inllammaiory  ■^w clliiiL;-  nia\  indicate  that  the 
bronciius  is  imaded.  A  probe  may  be  reipiiiccl  to  lociite  the  forei.nii 
body.     A  >nction  apparatus  is  useful  foi-  reinoviiiL;-  Iramueiits  of  seeds. 

The  After-Eflfects  of  the  Removal  of  Foreign  Bodies. — Unless 
edema  of  the  larynx  follows  the  manipulations  reipiired  for  the  removal 
of  a  forei.i;-n  l)ody,  the  after-effects  of  l)ronchosco])y  are  slij^lit.  There 
may  be  some  hoarseness  for  few  days  or  a  sliiiht  locali/.eil  l)idiicliitis. 
This  is  trivial  and  soon  ilisaiijiears. 


210  OPEKATIVK    STT>(!Kr>V    OF   THE    XOSE,    TTIKOAT,    AXD    EAR. 

ESOPHAGOSCOPY. 

History. — Soon  after  tlu;  iuveution  of  tlie  laryngoscope  attempts 
were  made  to  see  the  opening  of  tlie  esophagus  by  pulling  the  cricoid 
cartihige  forward  with  apj^ropriate  specula  and  then  obtaining  a  view 
l)y  means  of  a  mirror  held  above  in  the  ])harynx.  These  expei'iments 
led  to  no  ])raetical  results.  In  1868  Bevan  liy  means  of  a  tliiu  s]ieculum, 
and  two  years  later  Waldenbnrg  l»y  means  of  a  tuliular  s])i'culnm 
14  cm.  long  succeeded  in  seeing  tlic  mouth  of  tlio  esojjliagus.  The  latter 
also  made  an  ocular  diagnosis  of  a  diverticulum. 

Stork  was  the  first  man  to  pass  a  solid  tube  into  the  eso})hagus  and 
to  carry  out  direct  esophagoscopy.  Kussmaul  (1868)  explored  the 
esophagus  with  a  rigid  tube  and  published  his  observations  on  the  nor- 
mal and  the  diseased  esojthagus,  while  his  pupil  Miiller  established  the 
important  clinical  fact  tliat  the  normal  esophagus  should  admit  a  tube 
13  mm.  in  diameter.  The  observ^ations  of  Kussmaul,  however,  made 
little  headway;  later  they  were  revived  and  i)oi)ularized  by  Killian. 

Stork  and  Kussmaul,  then,  were  the  two  men  who  gave  esophagos- 
copy its  start.  V.  ]\Iikulicz,  a  follower  of  Stiirk,  was  the  next  worker 
Avliose  results  jjroved  to  be  fundamental.  By  the  year  1881  he  had  car- 
ried out  most  important  anatomic  and  physiologic  researches  and  had 
noted  common  pathologic  changes.  For  the  next  ten  years  no  s]iecial 
advances  in  esophagoscopy  were  made.  Since  that  time  this  method  of 
investigation  has  been  pursued  with  vigor.  The  advances  have  l)een 
along  the  line  of  improved  technic  and  new  instruments. 

Anatomy. — The  esophagus  is  a  muscular  tube  which  is  the  con- 
tinuation of  the  pharynx.  It  starts  from  the  back  of  the  cricoid  car- 
tilage opposite  the  sixth  cervical  vertebra.  At  the  mouth  of  the  esopha- 
gus the  lower  border  of  the  inferior  constrictor  muscle  projects  like  a 
mound  into  its  lumen  and  acts  as  a  sphincter  in  a  way  similar  to  the 
action  of  the  superior  constrictor  (Passavant's  fold)  in  the  upper  part 
of  the  i^haiynx. 

Structure. — The  esophagus  has  an  outer  muscular  coat  of  two 
layers  and  an  inner  glandular  coat  covered  with  pavement  epithelium. 
A  connective  tissue  layer  joins  the  two  chief  layers.  The  thickness  of 
the  esophagus  is  3  to  4  mm.  The  outer  layer  of  the  muscular  part  con- 
sists of  longitudinal  fibers  and  the  inner  layer  of  circular  ones.  (Fig. 
156.)  The  anterior  longitudinal  fibers  are  attached  to  the  back  of  the 
cricoid  cartilage.  The  inner  layer  of  circular  muscular  fibers  is  a  con- 
tinuation downward  of  the  fibers  of  the  inferior  constrictor  muscle. 
The  upper  end  of  the  esoijhagus  therefore  is  the  lower  end  of  the 
pharynx,  so  that  voluntary  musciilar  fibers  ])red()minate.     From  this 


I.Ai;VX(insl(irV.    llKONCIIoSCdl'V.    KSllIMIACIISCdPV.    KTC. 


211 


^^s?c**fc- 


it  lia|i|K'iis  that  a  l'(irci>;ii  body  anotfil  at  llic  ciiti-aiicc  of  llic  csoiiliii- 
,U'Us  is  oftoii  tlirowii  hack  into  tlic  pliaiyiis  and  into  tin'  inonti:. 

Lymphatics. — Tiic  lyniiiinitii-  nl'  ihr  fsopiiaf^nis  cnlcr  liotli  llio 
nicdiaslinal  and  tiic  ciTvical  i;land>  xi  llial  in  susp(>ct('d  caiHTr  ol'  liio 
oso|ilia,ii-us  llu'  glands  at  tiu'  root  of  llir  lun-k  -lionid  lie  I'xamincd. 

Position,  'i'lif  ('sojiiian-ns  lia>  tlir  \ crti'lnal  colnnm  lirhind  i)  and 
llir  irarlira  in  iVoiil,  and  lii's  in  tin'  |io>ti'i-ior  nii'iliasl  Innni.  .\t  the 
fourth  tiiorai'ic  vortei)rii  tiie  arcli 
of  the  aorta  makes  a  transverse  oon- 
stric'tion  in  it  and  a  vert('l)ra  h)\ver 
down,  the  kd't  main  hronclins.  at  tiie 
fit'tli  tiioracic,  makes  an  (il)li(|Uo  lim' 
across  its  front  surface.  l5cio\v  this 
point  the  iicart  lies  on  it  lilve  a 
wi'iii'iit.  In  llic  liiwiT  jiart.  the  rinlit 
and  left  ]incuninL;ast  ric  iicrxcs  lie  on 
tlu'  sides  of  tiic  csoiiha-ns.  and  hack 
of  liic  arch  of  tlic  aoi-ta  the  thoi'acic 
duct  crosses  from  ri-lit  to  left  Ih^ 
hind  it.  on  the  fi-onl  of  ihc  xcilchral 
cohinin.     I  j-'ii;-.  l.'i". ) 

Direction. — The  .■>opliai:iis  is 
ph-iccd  for  tlu^  nio>t  jiarl  a  litlic  to 
the  h'ft  of  tlie  niiddh'  line.  .Midway 
in  its  coni'se.  at  the  fourth  thoracic 
vertebra,   it   swings   to   the   central  Fig.  15G. 

line.  l)ack  of  tlie  arch  of  the  aorta.        scctimi  of  the  iium.in  osophaRiis  (Mod- 
hut    at    once   f?OeS    to    the    left    a"-ain       '^^■•ately  magaifiecl).     The  sect;,...   is  trans- 

'^  verse,   ana    iro.n   near   the   middle   of   the 

and    entel'S    the    stomach    lo    the    bd't       gullet.     (Quain'.s  Anato.nv — Fro...  a  draw- 

an.l    in    fmnt    of   the   ao,la.   a1    the  i"K  by  V.  Horsley.) 

,  n,  i.l)rous   eovenng;    h,   d.v.ded    nlieis   ol 

cle\-entli     thoracic     \er1elira.        This  the    longitudinal    muscular    coat;    e,    trans- 

1    , .  ■     ,  ■          ,■             ,1                ,           ,                 ,  verse    muscular     filters ;     d,    submucous     or 

'■''^  '■■'"""    ''""I    ""■   '•'•liter   do.'S    not  ,,„,olar    layer;     c.    .nu.scularis    mucosa;;    /, 

interfere    witil    the    passim;-    of    hou-  '""cous    memh.a.ie,    with    vessels    and    part 

of    a   lymphoid    nodule:    fl,    la.nii.ated    epi- 

fJH'S    or    tube>    except     at     the     lower  Ihelial    lining;    h.    mucous    gland:    i.    gland 

.    ,    .         I              .1                    ,                      •  duct;      m,     stri.-ited      muscular      fibers      cut 

part   where   tlie   esopliaf,nis   ])ierces     ;n.r„ss. 
the  diaplira<riii.  (Fiii-s.  LIS  and  1.")!).) 

The  Diameter.  Only  in  the  region  of  the  mouth  of  the  esoiibayus 
is  the  diameter  relatixcly  lixiMl.  The  esophagus  is  constricted  at  four 
points.  <  )f  these  the  uppi'r  and  the  Iowit  ones  are  the  most  impoi'tant. 
The  upjier  oiii'  is  caused  by  I  lie  proJecii(jn  b;ick\\  aid  of  till'  cricoid  carli- 
laji'c,   ihu   lowei-   by    llie   eiiei  rcliiiL;-    fibres   of   tlie   diaphrauiii.     TIlc   up- 


212 


OPKJ'vATlVK    srnOKIlV    OK    TIIF.    NOSE,    TIIIIOAT,    AND    EAU. 


])er  one  hiudors  tho  inlroductioii  of  the  exaininiiiu-  tnl)(\  tin*  lower 
one  obstructs  the  passage  of  the  esophag"oyeoi)('  into  tlic  stoniacli. 
TIk'  iirst  eoiistrietioii  is  a  transverse  slit,  sliohtly  less  than  an  ineli 
wi(h';  the  second  constriction  is  abont  of  the  same  width.  The  hm^ 
axis  of  this  constriction  is  fi'om   ri,i;ht   to   left    from    hehiml    I'ni-ward. 


Right  common  carotid  artery 


Lairngeal  part  of  the  pharyn 
Par>  laryngea  ph.io'nfii'i 
Thyroid  body 

Glandula  lliyrcoidi 


Superior  mediastinum 

Descending 
Aorla  clcsceddcn 


Broncho-  £sophageu3  muscle 
Pleuro-  esophageus  muscle 


Phrenocostal  i  diaphragm  at  ico 
•  costal)  supplemcQtal  pleural 

Sinu5  phrrnictJco>ialis  pk-iir 


Descending  thoracic  aorta 


Fig-.  l.-,7. 
Showing   the   leljitioiis   of   tlie   esophagus  from   Ir-IuikI.      (From   Tohlt.) 


Tlie  Inmen  of  the  esophag'us  at  tliis  point  is  sul)ject  to  Avide  variations 
which  depend  ni)on  tlie  relaxation  or  the  contraction  of  the  diaphragm. 
In  addition  to  these  two  important  constrictions  there  are  two  others. 

()fl(Mi  tliev  are  not  seen  unless  closely  watclied  for,  and  they  disa])]>ear 


I.AIIVNiUPX  ii|'\  ,    1. 


•  t\.    i.^wi  ilACOSCorV,    HTC. 


ui;: 


coiiiiilctrly  il'  Inriic  tiilics  ;uc  u>^i't\.  'I'lic  lirst  >>['  tlioc  iiiiiinr  cniislrii-- 
lions  convsiHinds  to  the  :irch  of  llir  anit.-i.  mikI  is  rniiinl  ;il  tln'  level  <if 
the    iinictidll   of  tile   lirst    ;iUtl   secoliil    liieees   cil'  the   slerilUIll   :illil    ill    IVoIlt 


-9 


y/.;.:F 


Fig.  158. 

View  of  tlic  stomach  in  situ  after  removal  of  the  liver  and  tlic  intcsline 
(I'xcept  the  duoilcnurri  ami  conniu'ncenient  of  jojuninn).  ((^ii.ain,  aftrr 
Testut.) 

A,  diai)hra;;ni ;  15,  15',  lliorafieo-alidoniinal  |iariel<'s;  (',  ri;;li(  l<idnev  with 
c,  its  ureter;  1),  right  suprarenal  rajisule;  K,  loft  kidney  with  <•,  its  ureter; 
F,  spleen;  G,  G',  aponeuroses  of  the  transverse  abdominal  muscles;  II,  rij,jht 
(juadratus  hnnhorum  niuselc;  11',  left  ditto;  I,  ri<;ht  psoas  niajtnus  and 
parvus  nuisides;  I',  left  ditto;  K,  esopliagus;  L,  stonuioh;  M,  duodenum; 
X,  jejunum ;  the  jiosition  of  the  duodeiio-jeiunal  junction  behind  the  stomach 
is  indicated  by  dotted  lines.  1,  termination  of  esophagus;  2,  jjreal  curv- 
ature of  stomach;  3,  snuill  curvatuie;  4,  fur.dus;  5,  antrum  pylori;  U,  jiyloric 
end;  7,  riyht  vagus  nerve;  JS,  left  ditto;  il,  thoracic  aorta;  9',  abdominal 
aorta:  10,  inferior  phrenic  artery;  11,  celiac  axis;  12,  lu'patic  artery;  i:i, 
rijjht  jj;astro-epi|>loic ;  14,  coronary  artery;  ];),  splenic  artery;  l(i,  Ifi',  su|h'- 
rior  mesenteric  artery  and  vein;  17,  inferior  mesenteric  artery;  I.S, 
spermatic  arteries;  ]!),  gall  bladder;  L'O,  cystic  iluct;  21,  hepatic  iluct : 
22,   inferior  vena  cava;   2:5,  |)ortnl    vein;    24,  syinjiathetic   cord. 


of   the    I'ninth    lh(ir;icie    \eitelir;i.      'I'lie    hi>I 
third   iVtiiii   ;iii(i\'e  c  hiw  iiw  ;in  L  i,--  iii;i(le   li\'   lin 


iii>t  riet  imi.    w  hieii    is    tlic 
•i(i^>iiii;   of  1  he   lel't    iiroll- 


214 


OPERATIVE   srUCiERY   OF   THE   XOSE,   THROAT,   AND   EAR. 


chus  in  front  of  tlic  esoplia^us.  It  oecni's  at  tln'  level  of  tlic  fit'tlt 
thoi'aeic  vertebra. 

The  Length  of  the  Esophagus. — In  men  the  distance  from  the  in- 
cisor teeth  to  the  bei^inninj;'  of  the  esoi)liai;us  is  15  cm.  and  in  women 
14  cm.  The  distance  from  the  incisor  teeth  to  the  liifnrcation  of  the 
aorta  is  26  cm.  in  men,  and  24  cm.  in  women.  In  men  the  length  of  the 
esopliagns  from  the  incisor  teeth  varies  between  36  cm.  and  59  cm.,  the 
nonnal  average  distance  being-  40  cm.  In  women  the  figures  are  a  little 
smaller,  32  to  41,  the  average  being  38  cm.  When  flexible  bougies  are 
nsed  for  measuring  1  to  3  cm.  should  bo  added  to  these  measurements. 

Distensibility. — All  the  constiictions  of  the  eso))hagus  are  dis- 
tensible. The  ujiper  constriction  is  less  dilatable  than  the  others,  so 
that  this  is  the  one  which  gives  the  greatest  tronlile  in  e80])hagoscopy. 

The  normal  esophageal  Avail,  according  to  Jackson,  will  stretch  2 
cm.  without  rupture.    At  times  foreign  bodies  stretch  it  more  than  this. 


Fig.  139. 
Under  sinfjii'O  of  the  liaphi-agm.  E,  Hiatus  csopliagiis.     Kote  the  direc- 
tiou  of  its  axis.     (After  Jackson.) 

In  infants  a  tube  of  7  mm.  should  pass  readily  and  in  the  adult  a 
tube  Avhich  has  a  diameter  of  14  mm.  In  infants  a  flexible  bougie  8 
mm.  should  pass  and  in  adults  one  that  measures  14  mm. 

With  light  stretching  the  transverse  diameter  of  the  esopihagus  is 
23  mm.  at  the  cricoid  cartilage  and  17  nmi.  anteroposteriorly.  The 
diameter  of  the  esophagus  as  it  goes  through  the  diaphragm  is  24  to 
25  mm.  Two  stomach  tubes  can  be  passed  side  by  side.  Briinings 
states  that  the  esophagus  at  its  mouth  can  be  dilated  to  30  mm.  Avithont 
danger. 

At  the  lower  end  of  the  esophagus  V.  Mikulicz  in  his  operation  for 
cardiospasm  stretched  the  lumen  to  7  cm.  so  that  the  hiatus  had  a  cir- 
cumference of  16  cm. 


L.\RYXnOS((il'\,    lil;<i.Ni   II 


ir\.  i..--iii'ii.\<.(i.--r«n"i ,  KH' 


ll'y 


The  (listonsiliilily  of  tin-  csopliaiifus  is  imu-li  KroattT  in  llic  livin<f 
tlian  ill  the  ilc;i(l.  ( iii  llir  ilc;i<i.  wliou  llio  osophaj^us  is  stretclicd  traiis- 
\i'rsrly  diily  it  tlilatrs  t(i  4(1  imii..  nr  (Hu-  ;iihl  <hm'  Ii;iII"  inclics.  TIic 
i)rilin;ir\  full  sizod  tootli  plate  is  two  ;iii(l  (Uif  i|ii;iiti'r  iiiclics  ( .")"  iiiiii.) 
tiroad.  A  ririy-ociit  \nvvv  is  oiic  ,iiiil  (iiic-i'ij;litli  iiielies  (oU  iiiiii.)  wide. 
Sinci'  till'  traiisvci'sc  diaiiu'tcr  of  tiir  csopliaji'iis  is  about  one  incii  it 
would  siM'iii  as  if  tins  coin  siiould  jjass  readily  in  an  adult,  'i'lie  direo- 
tiou  in  wliieli  the  esophagus  will  stroteli 
the  most  is  from  side  to  side.  For  tJiis 
roasnu  oval  tulios  take  up  tlie  slack  in 
the  es(i|iliai;us  ahniu'  aiiatnniie  lines  l»et- 
ter  than  nuind  (Uies. 

The  Subphrenic  Portion  of  the  Esoph- 
agus.— J>eginiiin,a,-  at  the  level  of  the 
lii furcation  of  the  trachea  the  esn|ihagus 

eolllrs    to    tile    froUt    ailil    pUSSeS    o\'er    tllO 

desceiidiiiL;-  aorta  and  iMiters  the  alnlo- 
iiieii  throiii^h  the  hiatus  or  the  opeiiini;- 
in  tiie  diaplirau,iii.  This  suliphrenic  jiart 
of  the  esoiihauus  vai'ies  niiieli  in  shape 
according  as  the  stomach  is  empty  or 
distended.  Tii  ])ersons  of  spare  liuild  it 
has  a  lateral  range  of  movement  amount- 
ing to  10  or  1.")  cm.     (Fig.  UiO. ) 

The  Movements  of  the  Esophagxis. — 
The  esoidiagus  is  never  twice  alike  even 
in  the  same  individual.  At  the  level  of 
the  fourth  thoracic  vertebra  (24  cm. 
from  the  teeth)  the  throlihing  of  the 
ar:-li  of  the  aoi'ta  can  lie  seen  if  watched 

i  \f^.    160. 
for  and   a    little   lower  at    the   |e\r|   of  the  ,s,.|K.nia     sliowiiij;     the     ranse     of 

seventh  and  ei-llth   thoracic  \ertehra  (."!()      """"'"     °^     ^''°    ga.stroa.-opo     nt     the 

mouth   of  the   esophagus   ami   at  the 
cm.    Irom    the    incisor-   teeth).      The   back-     hiatus     of     the     diaphragm.     (After 

ward   mounding   of   the    heart     an<l     its    •'='<''^«°°-) 
beating  are  visible. 

If  a  relatively  small  esophagoseope  is  used  for  the  examination 
the  esophagus  oj)ens  with  inspiration  and  partially  closes  with  expira- 
tion. These  changes  occur  cliiell\  in  the  thoi-acic  ]i()rtion.  and  are  due 
to  the  negative  intrathoracic  ])ressure.  if  a  large  tube  is  used  the 
esophagus  stands  wide  open  after  the  cricoid  cartilage  has  been  passed 
and  the  respiratoi-y  changes  nearly  disappear. 

During  swallowing  |ieristaltic  movements  pass  along  the  eso]iha- 


•JKi 


(llMOItATIVK    .'^I'llCKltV    OK   THE    NO.Sl-:,    TIIIIOAT,    AKD    KAH. 


li'iis  tVoiii  ;ili()\-|'  (IdWiiwiirds,  while  in  \niiiirni,L;'  llic  imuxciiiciiIs  arc 
roxciscd. 

TluTe  is  .ii'""(l  ('N'idcncc  t(i  siipiHirt  tlu'  assei'tidii  llial  llici'c  is  a 
s))liiiictiT  at  the  cai-diac  end  of  the  esoi)hai>'us,  due  to  the  iircsciicc  of 
two  layers  of  imiseular  tihrcs  as  described  liy  llyrth  Acrordiiiii,-  to 
.Jackson,  the  i)reseiK'e  of  this  sphincter  is  not  the  chief  agency  tlirougii 
which  the  regurgitation  of  food  is  prevented.  This  oliserver  maintains 
that  the  kinking  of  the  esophagus  below  the  (i|ieniiig  of  tlie  diaphra.gm 
and  the  increase  of  this  twist  by  distension  of  the  stomach  has  much 
more  to  do  with  keeping  the  food  in  the  stomach  than  the  presence  of 
the  cardiac  sphinct(>r.  From  a  few  anatomic  findings  which  hav(!  come 
to  the  notice  of  the  aiitlmr  he  is  inclined  to  think  that  dackson's  posi- 
tion will  lie  sustained. 

Measurements  of  the  Esophagus. — The  following  tables  are  com- 
piled from  Stark.    They  are  of  use  for  reference. 

Diameters  of  the  EsopirAcrs  at  the  Foi'r  Con.strictioxs. 


Constriction. 

Diameter. 

Vertebra. 

Cricoid   

Transverse  2:1  mm.    (1  in.) 

Left   liionclms    

Fiftli  tlioracic. 

T)iii|iliv;i"ni    

Trniisverse  2.'i  mm.    (1  in.  -(-) 

Aiiteroposlevior  23  mm.   (1  in.  — ) 

Tcntli  tlun-Hcie. 

Length  of  thj.;  Esophagu.s  at  Differext  Ages. 


Length  of  Whole 

T 

>ctli  to 

Cricoid. 

To    Bit 

urcation. 

To 

Cardia 

Lsophagns 

Birth, 

7  cm. 

(2%   in.) 

12  em. 

(4%  in.) 

18 

em. 

(  (i% 

in.) 

10  cm.     (  4       in.) 

1  year, 

in  cm. 

(4       in.) 

14  cm. 

(•51/2  in.) 

22 

em. 

(   8% 

in.) 

12  cm.     (  4%  in.) 

2  veara, 

10   cm. 

(4        in.) 

^r>  cm. 

(G       in.) 

2.3 

em. 

(  9 

m.; 

13  cm.     (   uVs   in.) 

.")  years, 

10  cm. 

(i       in.) 

17  cm. 

(0%  ill.) 

26 

cm. 

(lOVi 

in.) 

Ki  cm.     (   6%  in.) 

10  years. 

10  cm. 

(4       in.) 

IS  cm. 

(7       in.) 

28 

cm. 

(11 

in.) 

IS  cm.     (   7       in.) 

l.T  years, 

14   cm. 

(.'■>%   in.) 

2o   em. 

(9       in.) 

33 

cm. 

(13 

in.  J 

m  cm.     (   7V0   m.) 

A.lult, 

l.~)  cm. 

M)        in.) 

2(>   cm. 

( 1014  in.) 

40 

em. 

(l.-i^i 

in.) 

25  cm.     (10       in.,1 

For  memorizing  the  length  of  the  esophagus  at  different  ages  the 
following  approximate  figures  are  given:  Birth,  7  inches;  5  years,  10 
inches;  15  years,  13  inches;  25  years  or  adult,  16  inches.  Add  three 
inches  for  every  five  years.    (Stark.) 


Diameter  of  Tubes  for  Differe.vt  Ages. 

To    8    years 

From  9  to  1.5  years 

From   17   years 12   ti 

Adnlts 


9  mm. 
11  mm. 
14  mm. 
14  mm.   (average.) 


LAr>VN(;(>si'opv.  nitoxciiosi'oi'Y,  Ksni'iiAdoscopv,  kic.  1!17 

Tlio  (>S()iili;i,u:us  Iti'.niiis  ()  iiirlii's  fniiu  llic  iiic-is(ir  tcrtli,  liacU  of  llic 
cricdiil  rnrtilaiii'  at  tlio  sixtli  cervical  vorti'hra.  It  is  10  iiiclics  lonir,  and 
uoos  tlirou<;li  tlio  diaplirai!:!!!  at  tlu'  tenth  thoracic  xrrf.'hr.i.  K!  inches 
iVdin  the  teetii.  It  is  crossed  l)y  thi'  arch  of  the  aoi-ta  hack  nl  llir  iniiMJe 
i<\'  till'  lir-t  jiiecc  of  tiie  stcnuim,  10  inches  rnim  i  he  led  h.  'I'lie  nieasnre- 
iniiit>  Id  lie  renieniliered  in  connection  with  it  aic  ihin.  (1  ami  10. 

Contraindications  to  Esophagoscopy.  'i'he  only  contraindications 
to  the  |ierl'orinani'e  ol'  csoiihauoscoiiy  aic  aeutc  inllainnialion  as  at'tiT 
the  swallowinn'  ot"  coirosixc  llnids,  and  aneurism  of  the  aorta.  Tiie 
clnet'  danuer  in  tlie  passage  of  tiic  esoiiiia.iioscope  is  mi'tnre  of  the 
esojjhaijus.  This  almost  always  results  in  infection  of  tin'  iiosterior  niedi- 
astiuuni  and  death.  Such  an  accidi'Ut  should  lie  easily  avoided  l)y  the 
selection  of  a  tnhe  of  the  iirojier  size  and  hy  adherinf;  always  to  the  fun- 
damental axiom  of  ail  esojihaiieal  examinations,  namely,  the  exaniin- 
inj;-  tuhe  must  lu-ver  !)e  advanced  uidess  the  eye  of  the  physician  sees 
the  ojHMi  eso]ihai;iis  ahead  throuijh  tlir  tuhe.  it  i>  \V(  II.  also,  to  remeui 
her  that  in  old  iiedplr  the  esophaii'eai  wall  may  lie  thin  eiiouuh  to  rup 
ture  of  itself  so  that  in  the  elderly  smaller  tnhcs  and  iireater  care  in 
usinii'  them  are  neces>ary.  It  has  dcvelopt'd  of  lati'  years  that  there  is 
consideralile  shock  from  me.nipulalinns  carrietl  out  in  the  esophaiiiis. 
Indeed,  working-  in  the  esoiihayus  causes  more  shock  than  working::  in 
the  trachea  and  Inonehi.  Relatively  children  ihi  not  liear  esophau:eal 
examinations  as  well  as  adults.  When  a  patient  is  ])0()rly  nourished, 
and  especially  if  he  is  on  the  point  of  starvation  from  the  presence  of 
a  stricture,  it  is  better  i)iactice  to  o])en  the  stomach  and  feed  the  jiationt 
through  a  gastric  fistula  until  his  resistance  has  been  restored  hefcu-e 
attempting  any  prolonged  esophageal  examination. 

Anesthesia. — The  eso))hagus  may  l)e  examined  lunler  local  or  gen- 
eral anesthesia.  In  Eurojiean  clinics  local  anestliesia  is  employed  for 
adults  almost  exclusively,  ('hildnu  ai'c  examined  under  ether  or 
ehlorcilni  m.  In  this  country  many  examinations  are  carried  out  under 
general  anesthesia.  The  aiitlmr  is  \('r>'  much  picjudiced  in  fa\'or  of  a 
general  anesthetic.  H'  the  manipulations  under  coeain  anesthesia  are 
successfnl  the  operator  gains  his  point,  Iml  if  the  examination  is  nega- 
tive no  conclusions  can  he  drawn  from  it  and  the  case  remains  in  doulit. 
On  the  other  hand,  if  the  examination  has  been  conducted  under  ether 
and  the  icsult  is  negative  liotli  the  jiatient  and  the  ])hysician  feel  con- 
tidence  in  the  tiinling.  I'nder  ether  larger  tulies  can  l)e  used  which 
means  a  better  view  iind  a  larger  liehl  for  the  maniiiulations.  In  addi- 
tion under  such  conditions  the  treatment  callecl  for  by  the  case,  for 
example  the  dilatation  of  a  strictni-e,  can  be  made  imue  efticieut. 

Instruments. —  In  exiphagoscopy  all  Inidgo  must  be  crossed  iu'fore 


218  OPERATIVK   SllKIEIIY   OF   THE   NOSE,   THROAT,   AXI)   EAU. 

the  operator  gets  to  tliem.  In  otlier  words  tlic  pliysiciau  iimst  be 
willing  to  supply  himself  at  the  beginning  of  his  work  in  this  line  witli 
a  full  set  of  general  and  special  instruments.  As  everything  depends 
upon  light  it  is  good  economy  to  have  two  sets  of  tubes,  one  set  being 
the  self -lighted  tubes  of  Einhorn- Jackson,  and  the  other  the  extension 
tube  of  Briinings  which  is  lighted  by  having  the  light  projected  through 
it  from  the  electroscope.     (Fig.  161.) 


Fig.  161. 
Jackson's  esopliagosciipe.     Tlie  drnina^e  tulic  runs  the  whole  length  of  the  instrument. 

The  list  recommended  is  as  follows: 

1.  One  7  mm.  Jackson  tube. 

2.  One  14  mm.  Jackson  tube. 

3.  One  adult  tubular  speculum  (Jackson). 

4.  One    tubular    siieeulum,    children's    size    (Jackson)  ;    or    one    adjustable    sjieculum 

(Mosher). 

5.  One  Briinings  '  or  Kahlor  's  electroscope. 

6.  One  Briinings'  extension  esoi^hagoscope,  about  7  mm. 

7.  One  Briinings'  extension  esophagoscope,  14  mm. 

8.  Nine  Coolidge's  cotton  carriers.     Tliree  25,  three  35,  and  three  50  cm.  long. 

9.  One    grasping    forceps   with   three    shafts — 25,    35,    and   50    cm.   long   respectively 

(Coolidge  or  .Tackson)  ;   or  one  extension  forceps   (Briinings)   with  three  tips — 
claw  toothed  tip,  tip  for  grasping  seeds,  and  a  punch  tip. 

10.  One  esophageal  dilator    (Briinings,   Mosher). 

11.  One   metal  probe  carrying  three   graduated   olives    (Bunt   pattern). 

12.  One   set   elastic  esophageal  bougies   from  the   smallest   size   to    No.   40    (French). 

The  series  should  be  complete  up  to  No.  20. 

13.  One  Casselberry 's  pin  cutter. 

14.  One  Jackson's  safety  pin  forceps;   or  one  Mosher 's  safety  pin  closing  tul.ie. 

15.  One   tooth  plate   cutter    (Kahler   or   Mosher). 

16.  One  metal  staff  having  a  perforated  olive  at  the  tip.     A  set  of  graduated  olives 

and  a  flexible  introducer  (Mixter  and  Mosher). 

17.  One    suction    ajiparatus.     Either    a   hand    bulb,    Jackson's    secretion    aspirator,    or 

a   suction   apparatus   run   by   electricity.     When   needed   this   last   apparatus   is 
a  great  luxury. 

The  author  does  most  of  his  esophageal  work  under  ether  and  pre- 
fers to  use  as  large  a  tube  as  the  esophagus  under  examination  Avill 
take.    Accordingly  he  uses  a  large  oval  tube  of  two  lengths.     (Fig.  162.) 


i.AitYXcoscorv.  luidXciKiscoi'v.  i:s()niA(i()S((irv.  i;ic. 


!l!) 


The  tulie  has  a  iiiaiidariii  wliicli  iirojcrls  iVdiii  llic  I'lid  an  iiicli  and  a 
half.  Thi'  pointed  end  of  tht-  phniircr  ivadily  finds  tlio  opcninif  of  the 
oso]»hai;ns  and  pushes  tlic  ciicoid  (•artih-ii:;e  forwanl  and  alhiws  the 
tube  to  sli|)  by.  The  IuIm'  h.is  no  seconchiry  tnlie  on  the  ontside  eitlior 
for  the  liii:lit  m-  fm-  -inliun.  The  tulie  is  liinefore  snntoth.  'I'iic  in- 
troduction of  tile  hwiiv  lulies  with  secondary  tnhes  on  tlie  side  is 
dangerous  because  the  tul)es  tend  to  cut.  The  autiior  had  one  fa- 
tality due  to  this  canse.  Instead  of  the  snction  tube  a  short  tube 
comes  (iff  froiii  the  main  tulir  near  ils  upper  end.  This  is  fur  the  intro- 
duction of  air.  The  tube  is  titled  with  a  iiMtal  plui;-  which  has  a  ghiss 
end.  When  this  wiiulow  ])lu,ii:  i><  in  piaie  the  esnidiairoscope  becomes 
essentially  airti.iiht  and  the  esopliaj;:ns  may  hf  liallonned  at  will  by 
closing-  the  tube  with  the  window  plug  and  then  foreiny  air  through  the 


Fig.  162. 
Moslior"s  sliort  longtii  oval  csopliaRoscopc.  This  tulio 
is  11  im-lios  (::s  ini. )  liiiiK.  i>"il  •>!  '"'''>  O'*  ">">■)  i" 
transverse  diameter.  Tlie  cut  slions  the  mcchaiiical  device 
which  loclis  the  lieaJ  of  the  lifjht  carrier  into  a  nolch  in 
the  side  of  tlie  tube.  This  arrangement  holils  the  carrier 
firmly  in  place  and  allows  the  insertion  of  the  air-ti)jlit 
window  plug  in  the  mouth  of  the  tube.  The  lower  end  of 
the  light  earner  passes  through  a  small  ring  inside  the 
oval  tube  and  near  the  lower  end.     (See  Fig.  163.) 


secondary  tube.  A  stout  foot  bellows  is  used  for  tliis  inirpose.  The 
light  carrier  runs  inside  of  the  main  tui>e.  and  as  it  is  not  incased 
in  a  small  tube  of  its  own  it  riuis  freely  id  all  times.  (Figs.  1()2-1()7.) 
'^riie  secondai'y   tube    fm-  the    light   carrier   is   bitten   and   (h'lited    i-on- 

finnally  so  that    llic  li.Ltht  enters  it   ] rl\-.     The  li-lil   of  tlir  o\al  tube 

is  incased  in  a  lincnj.  This  protects  it  duriuy  in^ertiun  and  while  tin' 
tube  is  in  use.  Tlie  liulit  once  adjusted  in  its  Imud  burns  much  Imiger 
than  when  it  is  exposed  to  the  danL;<  is  of  |iassiiii:'  tlirongh  the  sec- 
ondary tube.  p]ach  tube  is  lilted  with  a  see(uid  oi'  extra  carrier  so 
that  the  operator  seldom  has  tin'  aiiiioy.inec'  of  having  to  fit  a  new 
lamp  diii-ing  an  examination. 

The  General  Examination  of  the  Patient.  A  general  i)hysical 
e.xaminaliuii  of  the  patient  should  be  maile  Ik  fore  eso])hagoscopy  is 
attempted.  Aneurism  should  be  excluded  ami  the  condition  of  the 
heart  ascertained.     The  i)atieiit'>  ability   to  --wallow,  the  )daee  where 


220  OPERATIVE    SnUlERY    OF   THE    NO.SE.    THROAT,    AXD    EAR. 


-A,- 


\  --\ 


\n  \  °\  \  °-\  \ -x  \  "\  \ -x  \  ^\  ^:^ > -A  \ - \\^^2~5> 


Fig.  163 


Fig.  165. 


Fig    166. 


Fig.  16.'!. — Moslinr 's  csopliagosoope  (sliort  lengtli).  Tliis  tulie  is  made  in 
two  Iriigtlis — 11  iiiclies  (28  cm.)  and  17  inclics  (-13  cm.) 

Tlie  lower  tigiire  shows  tlie  metliod  of  lioiding  tlie  lower  end  of  t'.ie  liglit 
carrier  in  place  by  J>assing  it  through  a  small  ring  on  the  inside  of  the  niain 
tube. 

Fig.  104. — Hood  or  cap  which  protects  the  lamp.  This  arrangement  of 
the  light  carrier  the  author  has  found  more  satisfactory  than  the  acces.soiy 
channel  on  the  outside  of  the  tulje.  The  outside  channel  makes  a  rib  which 
on  larger  tubes  tends  to  cut  the  soft  tissue.  The  outside  channel  is  con- 
stantly becoming  dented  so  that  the  light  carrier  runs  poorly  and  the  con- 
tact of  the  lamp  is  disturbed.  When  the  light  carrier  runs  inside  the  tube 
and  is  protected  by  the  hood  there  is  much  less  trouble  in  keeping  the  light 
in  good  condition. 

Fig.  16.5. — Long  conical  plunger  for  Jlosher's  oval  esophagoscope.  This 
jdunger  extends  beyond  the  end  of  the  tube  ]i{)  in.  This  plunger  readily 
enters  the  esophagus  and  pries  the  cricoid  cartilage  forward  and  allows 
the  tube  to  follow  after  easily. 

Fig.  166. — Window  plug  for  making  tlie  esojihagoscope  air  tigi-i  and 
ballooning  the  esophagus. 

Fig.   167. — Diffei'ent   sizes  of  Moslier  "s  oval   esophagoscopes. 


I.AlIVXCdSl'OI'V,    KllOXCIIOSCOrV.    KSOl'llAC.DSrol'Y,    KTC.  --I 

lie  loc-ati's  liis  tnnililc.  ami  all  tlu'  tli'tails  aliout  ici;iir,i,ntati<)ii  nr  vmiiit 
iiii;:  aio  iiupdrtaiit  to  olitaiu.  The  coiulitioii  i>t"  tlic  tt-ctli  is  olisi-rvcd 
and  the  pri'siMicc  of  crowns  or  lnidn'cs  iiolcd  and  rcnicinhiTiMl.  The 
examination  ot'  tlie  month  and  pliaiynx  sliotdd  know  the  existence 
of  nleeratioiis  or  sears  and  the  iaryn,noseo|)e  will  iiive  the  condition 
of  the  larynx.  If  disease  is  present  in  the  larynx  it  is  often  a  ]iiirt 
of  a  similar  process  in  the  esophaji^us  or  a  clew  to  it.  An  X-ray  ])late 
is  indispensal)le  before  many  examinations.  Tiie  plate  shows  the  lo- 
cation of  metallic  forei.nn  IkhIus  and  pieces  of  lionc  and  Imltons;  it 
>liows  enlarnement  of  the  arch  of  the  aorta  and  i'nlar.i;enient  of  tiir 
mediastinal  glands,  and  combined  with  the  ingestion  of  bismnth  it 
shows  the  position  of  strictnres,  the  size  and  location  of  diverticnla, 
and  the  size  of  the  dilated  esophagns. 

The  old  practice  of  passing  a  bongie  into  the  esophagns  shonlil  l)o 
given  up  in  most  cases.  If  a  foreign  body  is  present  the  bougie  may 
push  it  down  or  impact  it  or  pass  by  and  fail  to  locate  it.  If  a  carci- 
noma is  present  it  will  start  Idooding  and  make  the  esoi)hageal  exam- 
ination more  dil'licull.  Many  palii'uts  haxc  been  killed  by  forcing  a 
bougie  through  the  carcinomatous  esophageal  wall.  If  the  i)hysician 
is  dealing  with  a  case  of  cicatricial  stenosis  of  the  eso|ihagns  or  a  iionch, 
the  bougie  is  safe  and  may  iiive  \alual)le  data.  The  infoi'ination.  how- 
ever, is  much  bettei-  gained  liy  the  esophageal  examination  with  the 
tube. 

In  speaking  of  the  risks  of  esopliai^dsedpy  it  was  staled  that  the 
greatest  danger  was  the  liability  of  peil'oraling  the  esophagus.  This 
can  liapp(Mi  before  the  exaiiiiiiatinn,  as  well  as  dnrini;'  it.  Tf,  therefore, 
a  case  pre>ents  itself  for  exaiiiinat ion  and  the  patient  lias  great  jiain 
on  swallowing  ahmg  the  line  of  the  sterniini.  if  the  respirations  are  in- 
ci'eased.  if  fewr  is  pi-esi^ut.  and  there  i-  eiiipiiyseiiia  of  the  skin,  the 
physician   should   suspect    that    the  esojihagns   has   ali'eady   lieiMi    pi^fo- 

rated  and  tliat  an  abscess  is  deN'eloping  in  the  i Iia>tinnni.     In  ,-ui-h 

a  case  (Irainaiic  of  the  nhscess  is  indicati'd.  not  esopliauoscopv. 

The  patient  >li(iul<l  he  examined  with  an  iMiipty  stomach  and  if 
possihle  with   an  empty  esophagus. 

Tiie  ease  of  esophagoscopy  under  local  anesthesia  deiicnds  npmi 
tlie  tolerance  of  the  ])atient's  pha:  >  n\.  P)runiugs  has  a  long,  thin  longiu> 
dei)ressor  with  which  he  tests  the  sensiti\-enes<  of  the  patient.  The 
first  introduction  of  the  cotton  swab  in  the  preliminary  application  of 

eocain  does  ju-t  as  well  auil  s settles  the  (|Uestion  as  to  whetlier  or 

not  the  subject  is  an  intolerahle  gagger.  The  experienced  examinei- 
always  looks  with  anxii'ty  at  the  patient 's  neck  and  teeth.  If  the  upper 
jaw  does  not  )irojeet  and  if  the  teeth  ai'e  short,  nr  better  Mill,  if  there 


ll'l  OPERATIVE   SURGERY   OF   THE   NOSE,   THROAT,   AND   EAR. 

are  no  upper  teeth,  if  the  ueek  is  long  and  thin  and  the  lower  jaw  well 
rounded  at  the  angle  and  freely  movable  the  cliances  for  a  favorable 
examination  are  good.  When  opposite  conditions  are  present  the  ex- 
amination is  often  diffioult,  sometimes  impossible. 

Technic  of  Esophagoscopy  Under  Cocain  Anesthesia. — By  means 
of  an  appropriate  applicator,  that  of  Sajous  is  very  convenient,  a  ten 
per  cent  solution  of  cocain  is  applied  to  the  base  of  the  tongue  and  to 
the  posterior  pharyngeal  wall.  After  an  interval  of  a  few  minutes, 
under  guidance  of  the  laryngeal  mirror,  cocain  is  placed  on  the  tip 
of  the  epiglottis  and  alloAved  to  run  into  the  larynx.  After  another 
interval  of  some  minutes  the  swab  is  carried  down  on  the  posterior 
pharnigeal  wall  to  the  opening  of  the  esophagus  and  applied  at  this 
point  and  to  the  region  of  the  arytenoid  cartilages.  It  is  well  to  repeat 
this  deep  cocainization  at  least  once.  It  takes  from  fifteen  to  twenty 
minutes  to  olttaiu  a  satisfactory  cocainization. 

Position  of  the  Patient. — The  patient  can  be  examined  either  in 
the  sitting  position  or  on  his  back  Avith  the  head  over  the  end  of  the 
table  and  held  by  an  assistant.  The  sitting  position  is  best  adapted  to 
short  examinations.  It  is  easier  for  the  patient  especially  if  he  is  old 
or  stout.  "Where  it  is  essential  to  have  the  esophagus  clean  as  in  cases 
of  spasm  of  the  cardia  with  dilitation,  stricture,  or  the  presence  of  a 
foreign  body,  as  well  as  with  children  or  weak  or  sick  ]iatients,  the 
prone  position  is  preferable. 

If  the  sitting  position  is  adopted  the  patient  sits  on  a  low  stool 
25-30  cm.  in  height  and  an  assistant  stands  behind  him  and  holds  the 
head.  If  tile  patient  is  examined  on  a  table  he  may  be  placed  on  his 
back  or  on  his  side.  (_)f  the  two  lateral  positions  the  left  is  the  easier 
because  the  physician  works  with  tlie  right  hand.  If  the  teeth  are 
missing  on  the  right  side  of  the  upper  jaw  the  right  lateral  position  is 
preferable.  If  the  incisor  teeth  have  been  lost  the  i)idnc  ])()siti(m  is 
chosen.  This  position  is  selected  also  if  the  o])erator  wishes  to  pass 
the  esophagoscope  into  the  stomach  because  in  this  position  it  is  easier 
to  bring  the  shaft  of  the  esophagoscope  to  the  right  and  to  make  the 
l^oint  enter  the  hiatus  of  the  diaphragm  and  to  traverse  the  subphrenic 
piortion.  In  either  the  lateral  or  the  dorsal  positions  the  knees  are 
drawn  up  slightly  because  the  muscular  relaxation  caused  by  this 
makes  the  passage  of  the  tube  easier. 

The  Introduction  of  the  Esophagoscope  by  Sight. — The  ideal  way 
of  introducing  tlic  ('soplKii;()sco]>c  is  (d  insci't  it  under  the  guidance  of 
the  eye.  The  patient,  anesthetized  with  cocain,  is  placed  on  a  low 
stool,  and  an  assistant  stands  behind  him  and  holds  his  head.  Care 
should  be  taken  that  the  head  is  not  placed  too  far  back  as  exces- 


i..\i;yn(;i)si'(H'v.  niioxiiKiscdi'v,  l•;s(ll•llA(■.osl•(ll•^■,  kit.  -S.) 

sive  bai'kwanl  lu'iidiiii;-  iiitcrt'ncs  with  tlir  iiiscrtinii  of  tlio  iiistnimciit. 
The  room  is  darki'iiod  and  the  upper  pail  nl'  tin-  extension  I'soplia.^o- 
scope,  if  tlio  r)riininijs  tul)o  is  eiiosen.  i>  waiineil  and  smeared  willi 
vaseline  ami  attacliod  to  tlio  olectroseope.  The  operator  holds  tin-  upper 
lip  of  the  ])atient  nul  nf  tlie  \\;i\  with  the  thnml)  and  fore  tinker  of 
the  left  hand.  Tlie  liisl  pint  oT  llic  extension  esophaiioscope  is  really 
an  elongated  tnluilar  speenlum  eiidiui:  in  a  imiuted  lip.  It  is.  tiiere- 
forc,  introduced  like  liie  autiiseope.  Thai  is.  il  is  introdueed  into 
the  month  and  .-leadied  liy  the  tip  n{'  tlie  thuinli  i\\'  tlie  operator's  left 
hand,  is  carried  itack  oxei-  tlie  h.i-i'  of  the  tongue  until  the  sunnnit 
of  the  epiglottis  is  seen  ihrou-h  the  tiihe.  At  this  jioiut  the  handle  of 
the  g"astroseoi)e  is  raised  and  the  hiwci-  end  of  tiie  tube  is  pa.'^sed  over 
the  epiglottis.  The  shaft  of  the  tulie  is  elevated  nntil  it  lies  snngly 
against  the  physician's  forefinger  which  is  guarding  the  incisor  teetli 
or  the  gnms  if  these  teetli  are  missiui;-.  If  the  eiiiglottis  is  missed  the 
point  of  the  tnlie  is  alinn-t  certain  to  liriiiu'  nji  against  the  ]Histei-ior 
pharyngeal  wall  much  to  the  discomfort  of  the  jiaticnt.  After  the  tip 
of  the  epiglottis  is  recognized  and  passed,  the  end  of  the  tuiie  is  car 
ried  down  until  the  avyt<>uoid  cartilages  are  seen.  These  arc  readily 
made  out  if  the  patient  is  a>kcil  io  plioiiate.  The  point  of  tln^  tuhe  is 
now  swung  a  little  liackwanl  to  ch'ar  tln'  arytenoids  and  the  tnhe  is 
advanced  a  few  ceiitiiucters  to  the  opening  of  the  csopliagus.  Tiiis  aji- 
pears  as  a  transverse  slit.  The  end  of  the  tuhe  is  now  hiought  forward 
a  bit  in  order  to  o])en  the  esojihagns.  If  this  does  not  happen  tlu'  ])atient 
is  almost  sui-i'  to  swallow  and  wlicn  he  doo  -o,  the  tn1)e  slijis  into  the 
esophagus.  Sonielimes  the  patient  must  he  asked  to  swallow  before 
the  tube  will  di-op  in.  In  diflicult  introductions  the  jioint  of  the  tube 
may  l)e  iilace(l  di'ep  in  the  left  pyi'il'orni  sinus  and  then  swum;'  round  to 
the  niediau  line.  As  it  docs  thi>  it  pries  the  cricoid  cartila-c  forward. 
Once  past  the  ci'icoid  cai-tilai:v  the  prouress  of  the  tube  is  easy.  The 
tube  is  now  cairieil  down,  adv  aiicinu'  slowl\.  to  its  full  K'liiith.  the 
examiner  all  the  while  unidiiiL;  the  point  by  looking  through  the  tidie. 
The  tube  must  iie\er  he  advanced  unless  the  esoiihagus  ahead  is  o]icn 
to  receive  it.  A\'hen  the  tube  has  been  adxanced  to  its  limit  the  second 
tube  is  inserted  inside  the  lii'st  one  and  can-icd  down  by  si-ht.  When 
the  Jackson  tubular  >pcculuni  is  used  foi-  tlic  introduction  of  the  esoph- 
agoscojie  the  steps  are  the  same  a-  for  the  lii-t  r.iiiiiin--  tube,  .\f1er 
the  month  of  the  esoidiagus  ha~  hecii  located  and  made  to  lemain  open 
a  Jackson  esoi)liagosco))e  is  carried  througii  the  speculum  au'l  into  the 
esophagus.     The  speculum   i<  then  withdrawn. 

The  Introduction  of  the  Esophag-oscope  by  Means  of  a  Flexible 
Mandl-in   or  Bougfie.      .\    heaked.   ]iartiall\    open    -peculum    i.-   carried 


224  OPERATIVK    STRGEHV    OF    THE    I\"OSE,    THrxOAT,    AND    EAR. 

down  to  the  opening  of  the  esophag'us  and  a  snugly  litting  bougie  is 
passed  through  it  and  carried  into  the  esophagus.  The  speculum  is 
withdrawn  and  an  esojihagoscope  is  passed  over  the  bougie  into  the 
esophagus.  This  ]irocedure,  which  often  makes  the  introduction  of 
the  tube  very  easy,  sIkuiM  nevci'  l)c  used  when  it  is  the  purpose  of  the 
examiner  to  determine  the  condition  of  the  extreme  upper  end  of  the 
esophagus  or  when  a  foreign  body  is  impacted  in  this  locality.  Another 
method  of  using  the  bougie  as  a  guide  is  to  pass  a  Jackson  esophago- 
scope  of  the  proper  size  below  and  behind  the  arytenoid  cartilages  and 
then  into  the  opening  of  the  esophagus.  A  bougie  is  then  passed 
through  the  tube  and  finally  the  tube  is  pushed  down  over  the  bougie. 
The  Introduction  of  the  Esophagoscope  Under  General  Anesthesia. 
— The  patient  is  prepared  for  ether  in  the  usual  wa\'.  lie  is  given  an 
injection  of  one  one-hundredth  of  a  grain  of  atropin  and  one-sixth  of 
a  grain  of  morphin.  The  atropin  produces  a  nearly  dry  esophagus  ex- 
cept in  those  instances  in  which  the  esophagus  is  dilated  and  filled  with 
food  or  a  pouch  is  present  and  acts  as  a  reseiwoir.  A  suction  apparatus 
is  not  usually  necessary,  but  is  always  a  great  luxury.  The  author 
is  using  it  more  and  more.  If  the  operator  Avorks  sitting,  the  table  on 
which  the  patient  is  placed  should  be  of  the  proper  height  to  permit  the 
surgeon  to  work  at  ease.  If  the  operator  prefers  to  stand  the  table 
should  be  placed  on  a  platform  large  enough  to  hold  not  only  the  table 
but  the  stool  for  the  assistant  who  holds  the  head  and  for  the  etherizer. 
The  corner  of  the  platform  opposite  the  head  of  the  operating  table  is 
cut  out  to  allow  standing  room  for  the  operator.  During  the  examina- 
tion should  it  become  advisable  to  lower  the  head  of  the  patient  the 
operator  is  not  forced  to  work  on  his  knees.  An  assistant  holds  the 
patient's  head  over  the  end  of  the  table.  His  left  hand  supports  the 
patient's  head  and  his  left  knee  sujjports  his  hand  while  his  foot  rests 
upon  a  sup]iort  of  suitable  height.  The  assistant  should  so  grasji  the 
head  that  he  can  transfer  it  at  any  moment  to  the  physician,  be  ready 
to  receive  the  head  back  and  to  hold  it  in  the  new  position  indicated  by 
the  surgeon.  Thus  the  ])atient's  head  is  continually  passing  from  the 
hand  of  the  assistant  to  that  of  the  o])erator.  It  is  vital  that  the 
head  should  not  be  extended  too  far  backward.  If  this  is  done  the 
cricoid  cartilage  is  held  tightly  against  the  sixth  cervical  vertebra  and 
will  not  move  forward  before  the  advancing  tulie  without  the  applica- 
tion of  great  force.  A  rough  introduction  of  the  esophagoscope  may 
cause  sloughing  of  the  posterior  esophageal  wall.  This  may  have  a 
disastrous  outcome  in  a  weak  patient.  The  fonnation  of  the  mouth  of 
the  esophagus  calls  for  another  word.  It  is  bounded  in  front  by  the 
cartilaginous  ring  of  the  cricoid  cartilage  and  behind  by  the  body  of  the 


^.A^.v^"(l()s(■()l■^ .  hkonc  ll(ls(■lll'^ ,   i.>i>ni.\i.ns('nrY.  ktc.  __ •• 

sixth  I'orvical  vertebra,  (hily  di:  IIr-  siilc  wlicrc  tlic  px  rironii  sinuses 
load  into  it  arc  tlio  walls  fniniKi^nl  of  soft  tissues.  Tlie  natural  ciianui'l 
for  food  into  tlio  esopliaiius  is  liy  way  of  the  ))yriforni  sinuses  ami  ex- 
perience has  shown  that  the  ]iyrifnnn  sinus  is  the  natural  and  the  easiest 
channel  tlirous>h  whicii  In  |ia>s  tin-  eso|thai;'oseoi»e.  If  the  tulie  clKi-rii 
for  the  introduction  into  tht'  isopliaii'us  will  not  pass,  ihc  opiTator 
should  at  once  select  a  smaller  tui)c  until  one  is  fouuil  which  will  enter 
without  being  forced.  The  tubes  wliidi  arc  most  useful  accm-diui'-  to 
r>runin!is  are  10,  12  ami  14  mm.  I'laitically  every  iiatieut  will  admit 
a  tube  of  one  size  or  another  uiihss  the  Imdy  of  the  sixth  cervical 
vertebra  is  enlar,i;'ed,  or  the  ccr\  ica!  xcrtebra'  aiv  diseased. 

It  is  usually  possible  to  pass  the  tnlie  by  sight  aiul  this  methotl 
should  be  attemi)te<l  lirst.  Suppose  the  .lacksou  instruments  are  se- 
lected. The  procedure  of  iutrodiiciui''  the  esophagoscope  by  sight  is 
as  follows:  If  the  teeth  are  intact  or  if  they  consist  chiefly  of  stumiis 
those  of  the  upper  Jaw  are  proterted  liy  inserting  a  thin  aiuminum 
tooth  plate.  If  the  gum-  aiv  bare  of  teeth  the  u>e  of  the  tootii  lilate 
is  just  as  imiinrtant  I'or  tlie  later  (•(iinj'nrt  of  the  patient.  In  a  hard 
introduction,  no  matter  wliieh  iii-trument  is  used,  tile  tooth  ]ilate 
should  be  eiiiplo\i'i|  until  tiie  tuin'  is  well  in  the  esophagus  because 
notwithstanding  assertions  to  the  contrary,  teeth  may  lie  nicked, 
bi-okeu  or  forced  from  theii-  sockets.  Patients  do  not  I'cadily  forget 
such  an  (H-ciirrenre.  The  teeth,  then,  ha\'e  been  pi-otected  with  a 
tooth  plate  and  the  a-sistant  holds  the  head  bent  backward  moderately. 
The  jaws  are  kept  slightly  apai1  b>  a  gai;;  pim-ed  in  the  left  corner 
of  the  mouth,  ^fbe  tongue  is  made  to  lie  naturally  and  the  end  of 
the  tubular  siM'cnlum  is  cai-ried  along  the  centiai  I'urinw  (\l'  the  tongue, 
and  is  piished  foi'ward  and  downward  until  thi'  tip  nf  the  ejiiglottis 
is  recognized.  The  tiji  of  tiie  e|iiglotti>  and  then  the  body  of  the 
e])iglottis  are  ])icked  up  by  tiie  end  of  the  speenlum  in  turn  and 
drawn  forward  until  the  aivteuoids  appear.  Tiiese  in  tui'n  are  passed 
by  inseiling  the  point  of  till'  specnluiM  hehiiid  tlieni  and  Inrcii:- 
them  forwai-<l,  and  tiie  speciiluni  is  carried  >lill  further  down.  All 
the  time  the  ojieialor  is  niakinu  traction  forward.  When  the  liro])er 
depth  has  been  i-eaclied  the  back  of  the  cricoid  cartilage  is  encountere<l 
and  this  like  the  structures  abo\c  is  pushed  forward.  At  this  jioiut 
the  umutli  of  the  esophagus  open-  ami  the  operator  looks  iido  the 
lumen  of  the  esojibagns  for  a  eonsidei  alilc  distance.  In  fax'oi'ablc  cases. 
es])eeially  in  infants  and  eliildreii,  he  can  .see  down  the  esoi)hagus 
almost  to  the  inner  end  of  the  clavicles.  With  the  cricoid  I'artilagc 
drawn  foiward  and  the  mouth  of  the  esophagus  gaping  it  is  a  simple 
matter  to  pass  tlie  esophagoscope  tbnuigh  the  tubular  speculum  into 
tlie  esophagus,  to  remove  the  .slide  and  to  withdraw  the  speculum.     In- 


226  OPF.r.ATIVK    snuiEKV    OF    THE    XOSE,    THROAT,    AND   EAR. 

troduction  by  sight  is  tlie  ideal  method,  because  in  this  procedure  there 
are  no  blind  i)oints.  It  is  not  necessary  to  describe  the  introduction  by 
sight  of  the  Briinings  extension  esophagoscope.  The  first  ])art  of  his 
double  tube  takes  the  place  of  the  Jackson  tubular  speculum  and  is 
used  in  the  same  manner.  After  the  esophagoscope  has  been  inserted, 
if  the  purpose  of  the  examination  is  to  explore  the  whole  length  of  the 
esophagus,  pathologic  conditions  permitting,  the  tube  is  swung  to  the 
corner  of  the  mouth  on  the  right.  If  any  teeth  are  fortunately  missing 
on  tills  side  the  barrel  of  the  esophagoscope  is  made  to  lie  in  the  tooth 
gap.  Should  it  happen  tliat  the  missing  teeth  are  on  the  left  side  and 
the  introduction  diCficult  it  is  well  to  sliift  the  tube  to  the  left  corner  of 
the  mouth. 

The  Use  of  the  Adjustable  Speculum  for  the  Introduction  of  the 
Esophagoscope. — The  author  has  for  some  years  worked  with  his  open 
and  adjustable  speculum  for  the  examination  of  the  upper  end  of  the 
esopliagiis  and  for  the  introduction  of  the  esophagoscope.  The  specu- 
lum is  an  adjustable  tubular  speculum  Avitli  the  right  side  cut  away. 
Owing  to  this  fact  all  the  landmarks  of  the  pharynx  and  larynx  can  be 
seen  ahead  of  the  speculum  and  in  their  proper  perspective.  There  is 
a  large  lateral  excursion  for  the  eye,  which  reduces  the  eye  strain,  and 
makes  the  introduction  of  the  tube  easier,  thus  giving  a  greater  play 
for  instrumentation  about  the  arytenoids,  in  the  pyriform  sinus  and  in 
the  up])er  part  of  the  esophagTis.  The  speculum  is  introduced  in  the 
same  manner  as  the  tubular  speculum  of  Jackson.  Should  the  purpose 
of  the  examination  be  to  examine  the  esophagus  below  the  clavicles, 
the  cricoid  cartilage  is  pulled  forward,  the  upper  portion  of  the  esoph- 
agus is  exposed,  and  then  the  esophagoscope  is  passed  by  sight 
through  the  speculum  into  the  esophagus  and  the  speculum  taken  out. 
The  tooth  plate,  if  it  has  been  used,  is  retained  or  not  at  the  discretion 
of  the  examiner. 

Passing  the  Jackson  Esophagoscope  by  Sight. — The  Jackson 
esophagoscope  can  often  be  passed  liy  sight,  especially  if  a  tube  of 
moderate  size  is  selected.  The  manipulations  are  the  same  as  in  the 
introduction  of  the  tubular  speculum.  The  field  given  by  the  esophago- 
scope is,  of  course,  somewhat  smaller  than  that  which  is  given  by  the 
tubular  speculum.  This  difference  in  an  easy  examination  amounts  to 
nothing.  Wlien  the  esophagoscope  has  been  passed  by  sight  to  the 
arytenoid  cartilages  the  point  is  swung  to  the  right  into  the  pyriform 
sinus  and  entered  deeply  at  this  point.  AVlien  it  reaches  bottom,  so  to 
speak,  the  point  is  swung  back  to  the  middle  line.  As  this  occurs  the 
tube  forces  the  cricoid  cartilage  forward  and  slips  into  tlie  mouth  of 
the  esophagus. 

Passing  the  Oval  Tube  by  Sight. — As  tlie  author  has  done  prac- 


i,.\i;vM;i)sn)rv,  iiiioxciKisidi'V,  ksoimiacosccii'v,  i;tc'.  --i 

(ically  all  liis  wmU  ii|ioii  tin-  fsoi>liiii,Mis  iiihUt  ctluT  iiiicsllicsia,  lie 
profors  to  use  for  tlu'  isopliairt-al  i-xaiiiiiiatiou  as  larj^i-  a  luhc  as  tlii' 
esopliauus  can  lie  iiiaiK-  to  take.  Oval  tuln's  take  iiji  the  slack  of  the 
csoiihauiis  aloMn'  anatomic  lines  lietter  than  round  ones.  For  this 
reasim  the  writer  eMiiilii\>  l.-uuc  n\,il  tnhes.  Thc-i'  .nf  iiiiulc  in  two 
lengths — an  eleven-inch  tnlic  ami  an  eighteeii-incli  tul>c.  Sn  niaiiy  of 
the  pathologic  conditions  of  the  esophagus  arc  fnuihl  in  tlic  upper  part 
and  the  eye  strain  is  so  vastly  increased  liy  iDnkin^  thidugh  a  hmg 
tube  that  it  is  economy  of  eyesight  to  have  luhcs  of  two  lengths.  Tiie 
short  oval  tulte  is  selected  and  jiassed  hy  sight  to  the  right  pyriforni 
sinus.  At  this  ])oint  the  transverse  axis  of  the  tulie  is  Miaile  to  lie 
anteriorly  by  rotating  the  tube  to  tlie  right.  The  tube  will  then  sink 
further  into  the  sinus.  When  the  point  of  tiie  tube  is  as  far  in  the 
pyriform  sinus  as  it  will  go  without  being  forced,  the  tube  is  rotated 
tiack  to  its  oriyiual  ))ositioii  with  the  lonu'  axis  airain  transversi'.  As 
this  manipulation  i-  c-iiriiMl  out  tiie  iel'l  e<lt;-e  ol'  tlie  o\al  tnlie  in.-iniuites 
itself  behind  the  l>oily  of  ilie  eiieoid  eaitilaue,  thus  |iushin.n-  it  lorwanl. 
and  the  tube  enters  tlie  eso|iliaL;us.  All  tlnse  nianii)ulations  are  seen 
by  the  examiner  as  he  iiiiides  them  liiroiiiili  the  tube.  The  lield  which 
the  large  tube  gives  is  so  -upeiioi-  to  tiiat  allorded  by  a  I'ound  and 
smaller  tube  iliat  e\-ery  legitimate  ell'ort  >liouhl  lie  made  to  introduce 
as  large  a  tulie  into  the  eso]ihagus  as  will  pass  the  cricoid  cartilage. 
Even  a  large  oval  tube  seems  too  small  for  the  calibre  of  the  esojihagus 
once  the  cricoid  cartilage  has  been  ])assed.  The  examiner  gets  this 
impression  even  in  the  noniial  adult  esophagus,  to  say  nothing  of  the 
dilated  esoi>ha<:us  of  e,ii(lio>pa>ni. 

The  Passing  of  the  Esophagoscope  by  Aid  of  a  Mandrin  or  a 
Flexible  Bougie.  -  In  the  earl\  (la\s  of  the  esophai^dscope  it  wa-  almost 
always  intr()duee<|  hy  meaii>  of  a  iHo.jectinL;-  pluu,i:ei-  or  mandrin. 
.\1    lii>t    the   mandrill    had    a    rii;id   end:   latei-   IJeNiliie   t  i  p^   were  added. 

To   all    intent.-   and    piiipoM-    ll h-i-lic    hoii-ie    i>    a    mandrin    with 

a  llexible  li])  and  is  so  u^e(|  loihix.     The  niaihlrin  is  chielly  em])loyed 

with  the  finger  tip  introduction  of  il so]ihai;dscopc  oi-  the  gastro- 

seope.  There  is  no  great  or  \ital  olije<-tioii  to  the  use  of  the  man- 
drin if  the  examiner  is  sure  thai  the  ])atlioh)gic  condition  is  well 
down  the  esophagus  or  if,  as  in  gastroscopy,  he  is  to  i)ass  the  tube 
through  a  normal  eso])hagns.  The  ]>roce(bii-e  is  cai'rie<I  out  as  follows: 
The  examimr  holds  the  esophag(»cope  in  the  tight  hand  and  with 
his  thundj  steadies  the  hea<l  (d'  the  plun-er.  With  the  forelinger  of 
the  left  hand  he  feels  the  right  arytenoid  eartilaize  \i\  forcing  his  liniicr 
well  down  the  ]>atieiit's  )ihar\ii\.  .\Iouii'  the  inner  surface  of  the  left 
f(M-eliniier  of  the  examiuei-  tiie  esophaiioscope  is  can-ieil  iido  the  right 
p>'i-iform   >inus.     ^\'hen    the   end    of   the    in>trnment    has  ri'acheil    this 


228  OPEKATIVK    SI'I!(;K1;V    (IK    THE    NOSE,    TilTinAT,    AND    EAIl. 

point  a  littk'  twist  of  tlio  end  of  tlic  tiiKc  to  the  left  carries  the  tnbo  into 
tlio  csopha.nus.  Witli  a  tiilio  of  iiKMlium  nr  siiiali  dianiotor  tliis  nu'tiiod 
of  iiitrddui-tion  is  the  (|nic'kc'st  and  easiest.  The  disadvanta.iie  of  the 
prueedure  need  not  be  dwelt  npon  aftei'  what  lias  1)een  said  of  the 
advantage  of  the  introduction  by  siglit.  The  hirge  o\al  tube  whicli  is 
used  by  the  author  is  fitted  with  a  conical  rigid  plunger  wfiicli  projects 
iVom  tlie  end  of  the  tube  an  inch  and  a  half.  The  plunger  is  used 
in  tliose  cases  in  which  the  ocular  introduction  of  the  oval  tube  does 
not  succeed.  The  oval  tube  is  carried  down  by  sight  and  the  attempt 
is  made  to  ]iass  it  by  sight  after  the  method  which  has  just  been 
described.  If  this  fails  the  plunger  is  put  in  and  gently  forced  home. 
The  plunger  is  so  long  and  ])ointed  that  it  finds  its  way  liehind  the 
cricoid  cartilage,  dislocates  it  forward  and  allows  the  tul)e  to  follow 
on  after  it. 

The  introduction  of  the  esopliagoscope  Avith  flexible  bougies  is 
best  adapted  to  round  tubes.  The  bougie  can  first  be  introduced  by 
the  finger  tip  method  or  the  tube  can  be  carried  to  the  entrance  of  the 
esophagus  by  sight  and  then  the  bougie  passed  through  it  and  into  the 
esophagus.    The  tube  may  tlien  be  sli])iied  down  over  the  liougie. 

Tlie  impression  may  lun'e  been  given  by  what  has  been  said  con- 
cerning the  introduction  of  lai'ge  tubes  that  they  should  be  used  at 
all  costs.  This  is  not  the  impression  which  the  author  wishes  to  leave. 
If  a  large  tube  can  be  used,  and  it  can  be  used  under  ether  without 
danger  oftener  than  is  generally  recogiiized,  it  should  be  employed.  It 
must  be  remembered,  however,  that  if  the  introduction  of  a  chosen  tube 
is  not  easily  successful,  that  tube  should  be  discarded  at  once  for  a 
smaller  one.    Obstinacy  on  this  point  will  lead  to  disaster. 

The  Appearance  of  the  Normal  Esophagus.— I  ndcr  good  idumina- 
tion  the  color  of  the  mucous  membrane  of  the  esophagus  is  a  whitish 
pink  like  that  of  the  mouth.  Poorly  lighted  or  when  inflamed  the  color 
changes  to  a  red  of  varying  depth.  After  trauma,  the  mucous  mem- 
brane soon  becomes  edematous.  When  examined  with  small  tubes  the 
walls  of  the  esot»hagus  are  thrown  into  large  longitudinal  folds,  and  on 
looking  through  the  tube  they  are  seen  indenting  tlie  circumference 
of  the  central  dark  area  which  represents  the  lumen  of  tlie  esophagus. 
These  folds  are  especially  numerous  at  the  mouth  of  the  esophagus 
behind  the  cricoid  cartilage.  They  make  it  hard  in  be  sure  of  the 
pathologic  lesions  in  this  locality.  Below  the  cricoid  cartilage  and  in 
the  cervical  region  the  lumen  is  seen  to  enlarge  with  inspiration  and 
to  close  down  again,  but  not  entirely,  during  expiration.  When  a  large 
tube  is  used  the  examiner  can  often  look  down  the  esophagus  a  long 
way  ahead  of  it.    As  the  esopliagoscope  reaches  the  first  piece  of  the 


l.AKVNCOSfiilM  .    l!i;n.\(  mix  (IPS  .     i; 


slcnuiiii  tilt'  |iiils;itioii  ol'  llic  jutIi  of  the  aorta  ran  lii'  srcii  tliroii>ili 
tlic  anterior  wall.  A  littli-  lower  the  heart  iiioiuitls  into  t!ie  anteritir 
wall  on  the  left.  The  lieatinn'  of  the  heart  is  visilile  ami  when  thi' 
Inhe  has  jiasseil  lievontl  and  the  heart  lies  ajrainst   it,  the  tnlie  nlli  n 


Fifr.  ins. 


Fig.    171. 


Fig.  IfiS. — ^The  normal  esophagus  above  tlie  hiatus  of  tlu-  diaiihragni, 
ami  witli  the  tliaphragm  contracted. 

Fig.  KiO. — The  eso|iliagosco|ie  has  been  pushed  througli  the  hiatus  ol' 
the  diaphragm  and  entered  the  snbphrcnic  portion  of  the  esophagus.  The 
eliaraeteristic  hmgitudinal  folds  of  this  part  of  the  esophagus  nie  shoun. 
They  converge  to  tlie  left  upon  an  ill-defined  transverse  slit  whiih  is  the 
eardiac   oiicning. 

Fig.  170. — The  esophagoscopc  has  been  carried  through  the  cardiac  open- 
ing of  the  esopliagus  iato  the  stomach.  The  stomach  appears  as  a  funnel- 
shaped  cavity.     On  the  lower  wall  of  this  the  rugic  of  the  sfoniacli  are  seen. 

Fig.  171. — The  drawing  shows  the  esophagus  just  abnve  the  hiatus  of 
the  diaphragm.  The  patient  was  examined  under  ether  and  with  an  oval 
esophagoscopc.  On  the  jKitient's  right  tlie  rim  of  the  liiatus  is  partially 
contracted  anil  mounds  into  the  lumen  of  the  esoiihagus.  Later  in  the  ex- 
amination when  the  diajiliragm  became  fully  relaxed  this  ridge  dis- 
appeared. Below  and  beyond  the  ridge  the  subphrenic  portion  of  the 
esopliagus  is  seen.  Tlu!  characteristic  longitudinal  folds  veer  to  the  left 
and    end    in    the    cardiac    opening.      The    cardiac    opening   is    in   a    state    of 

I  niinvings   1  y   the   author.) 


vibrates  in  uniMin  with  tiic  heart  heat.  'I'lie  hiatus  of  the  esopiia.nns 
appears  a.s  a  slit  un  a  ru.~etle.  The  a.xis  of  this  opening-  throiiirh  the 
iliaphra.ain  is  oblique,  running-  from  linht  to  left,  from  behind  forward. 

The  subiihrenic  juirtioii  of  the  es(i)iliai;us  usually  shows  no  Iniiien.  but 


230 


OPKKATIVK   srn(lKi;Y   OF   THE   XOSE,   THROAT,   AXD   EAR. 


Fig.     17.: 


Fig.    174. 


Fig. 
5;oscope. 
Fig. 
Fig. 
Figs. 
Fig. 


172. — Normal    esophagus    during    quiet    breathing.      Small    csopha- 

173. — Normal   esojihagus   during   deep   respiration. 

174. — Stricture   of  esophagus  with  scars  radiating  from  its  lumen. 

175  and  176. — Carcinoma  of  the  esophagus. 

177. — Fish  bone  in   the   esophagus. 

(After  Stark.) 


i.Anvxr.osc'opv,  nKoxciidsrnpv,  KSdPiiAiiosropv.  i/rc.  2.'}1 

opoiis  ;is  till'  Inlii'  imsscs  llinmuli  it.  Tlu'  imi<Miiis  iiu'iiilpriiin-  of  lliis 
pjiil  is  -u  imii'li  likr  tii;it  III'  tlh'  >1niii;n-|i  that  it  is  lianl  to  tell  whore 
tile  t'soplia.mis  I'luls  and  (lie  stuiiiai-li  l)t',i;iiis.  Tlio  iiiufous  im'ml)niiKi 
of  tlio  stoniafh.  liowovor,  is  a  darker  red  tliaii  that  of  tho  ('S(i|ilia<j:us 
and  tile  Idimitudiiiai  foltis  of  tlic  csoiiiiaiiiis  iiivc  place  ti)  tlie  familiar 
roniic 

The  mouth  of  the  esopJiM-iis  and  the  hialn,-  aic  the  two  placi'S 
wliei-e  it  i-  alway.s  dilheult  for  the  examiner  to  he  >ui-e  of  iiis  liiidiiiKS. 
The  difficnlty  at  tlie  first  place  is  due  cliiofly  to  the  folds  of  tlio  mucous 
nu'uibrane.  Those  can  bo  strotclied  out  by  ])assin,ii:  the  esophairea] 
<iilator  well  into  tho  mouth  of  the  esophaiius  ami  oijoniui;-  it  sulTi- 
cienfly  to  displace  the  eiieoid  eartilai;!'  strongly  forward.  If  a  true 
well  is  susiiected  the  withdrawal  of  the  open  dilatoi-  will  make  its  size 
ami  ])osition  jilaiu.  Tlie  introduction  of  a  small  tube  through  the  pyri- 
form  sinus  is  very  liable  to  ])ush  a  fold  of  the  miu*ous  nn-mlirane  ahead 
of  it  and  produce  an  artificial  wi'b  or  fuld.  ( )iiee  the  i-rieoid  cartilage 
has  been  jiassed  the  further  jironress  of  the  esoiiha.:;tiscoi)e  is  usually 
easy.  The  exaniiiu'r  slnudd  always  see  the  open  esophagus  ahead 
through  the  tube  liet'ore  the  lube  is  advanced.  AVIien  no  lumen  apjiears 
the  end  of  the  tube  is  geiieially  pointed  too  much  to  the  side  and  is 
out  of  line  with  the  long  axis  of  the  esophagus.  If,  on  correcting  the 
])osition  of  the  tube,  the  lumen  of  the  esophagus  is  still  unnoticeable, 
its  ])osition  can  be  made  out  by  inserting  the  window  jilug  and  filling 
the  esophagus  with  aii'.  The  author  considers  this  ex)iodiency  of  the 
utmost  value.  ()nee  the  lumen  has  been  found  the  tube  can  be  carried 
further  down. 

In  order  to  enter  the  hiatus  it  is  lU'cessary  {o  carry  the  shaft  of  the 
esoiihagnscope  to  the  riglit  corner  of  the  nniuth  and  the  ])oint  of  the 
tube  to  tile  left,  beginning  tile  search  ill  the  rii;ii1  postcrioi-  i|uadrant 
of  tile  esophagus.  It  is  at  this  point  tiiat  the  hiatus  is  most  i-eadily 
found.  When  the  point  of  the  tube  eaiiiiot  be  made  to  enter  the  hiatus 
and  to  proceed  through  the  kinl<e<l  subphrenic  ]>ortion  of  the  eso])lia- 
gus.  a  bougie  passed  through  the  esoiihagoscope  ami  into  the  sub- 
|ilii-iMiie  |Mirii(iii  will  often  guide  tile  tiibe  into  t lio  stouiacli.  Tlu"  author 
relies  upon  ballooning  the  eso|iliagiis  and  thus  finding  his  way.  After 
the  esophagus  has  been  examined  all  the  way  to  the  stomach  the  tube 
is  withdrawn  and  the  whole  of  the  esopbagi'nl  wall  is  reexamined. 

THE  DISEASES  OF  THE  ESOPHAGUS. 

The  chief  symiitom  of  disease  of  tlie  esojihagns  is  olistrut'tion  to 
swallowing.  Diseases  of  the  esophagus,  therefore,  fall  into  two  groups, 
those    which    cause   marked    stenosis    and    those   which    do   not.      Xew 


■Jol:  ni'KiiATivK  srniiKr.v  or  tiik  xosk,  tihioat,  axd  eaii. 

UTiiwtlis  foi'iii  ail  important  sul),n-roiii).  As  elsewhere  in  the  body  a  new 
iirowtli  may  lie  heninii  or  mali.ii'iiant.  Foreign  bodies  in  the  esoi)liagns 
make  the  linal  inipoilant  group  to  be  considereil. 

DISEASES   OF   THE   ESOPHAGUS    WHICH    CACSE    STEXOSIS. 
Acute  Inflammation. 

l*'ollo\ving  the  swallowing  of  a  corrosive  such  as  lye  (washing 
jiowders),  carbohc  acid,  or  corrosive  sublimate,  the  eso])luigus  becomes 
acutely  inflamed  and  more  or  less  completely  closed.  Hough,  ini])aeted 
foreign  bodies  also  cause  a  local  inflammation.  This  may  be  more  or 
less  general  if  the  foreign  body  has  caused  extensive  trauma. 

After  the  swallowing  of  a  caustic  it  is  better  to  wait  for  a  few 
weeks,  perhaps  a  month  or  two  until  the  inflammatory  disturbance  has 
subsided  before  examining  the  esophagus  with  the  esophagoscope  or 
before  passing  bougies  by  the  aid  of  the  esophagoscope  in  the  hope  of 
preventing  the  formation  of  cicatricial  strictures.  This  caution  is 
especially  necessary  in  dealing  with  young  children.  In  such  cases  it 
is  probably  better  to  open  the  stomach  without  delay  and  to  nourish 
the  child  through  the  gastric  tistula  until  it  has  regained  its  powers  of 
resistance  and  is  once  more  well  nourished.  If  a  foreign  body  has 
caused  the  inflammatory  stenosis  of  the  esophagus,  it  must  lie  removed 
at  once. 

Stenosis  of  the  Esophagus  Due  to  Cicatrices. 

Cicatricial  stenosis  of  the  esojihagus  may  be  the  result  of  opera- 
tion, i.  e.,  removal  of  the  glands  of  the  neck,  or  excision  of  the  larynx. 
Traumatic  stenoses  are  caused  by  gunshot  wounds  and  by  swallowing 
sliarjj  foreign  bodies.  Systemic  diseases,  which  are  at  times  associated 
with  ulcerations  of  the  esophagus,  may  also  cause  cicatricial  stenoses. 
Sy]iliilis  and  tyjihoid  fever  are  occasionally  responsible  for  such  stric- 
tures. Pneumonia  may  ])roduce  the  same  condition,  Imt  cicatricial 
strictures  are  most  common  after  the  swallowing  of  some  escharotic. 
When  home-made  soap  was  common,  children  drank  it  by  mistake. 
Today  they  drink  solutions  of  corrosive  sublimate,  which  are  kept  to 
destroy  vermin,  or  the  ^'arious  wfishing  compounds  containing  caustic 
soda. 

It  may  be  years  before  cicatricial  strictures  finally  shut  down. 
Adult  patients  not  infrequently  present  themselves  who  give  a  history 
of  having  swtillowed  some  caustic  in  childhood  and  who  have  had  only 
moderate  difficulty  in  swallowing  for  years. 

The  Location  of  Strictures. — Caustic  strictures  form  most  readily 
at  the  jioint  where  the  eso])hagus  is  the  narrowest.     They  are  found. 


i,.\i;vN(;osr(ii'\ .  itiKiNrimsi  ni'\ .  |■.sl)l■ll.\<;llS(•l>l•^ .   kit.  _.>.> 

lluTi-rori'.  most  cuimimiily  at  llir  ii|'1iit  m-  Idw.T  ohI  d'  the  rsopliii.-^-us. 
(tccasioiially  a  strictniv  is  louml  at  tlif  I.'mI  i.f  tlic>  clav  icli'>.  Xol  uii- 
i-onimonly  t\u'\\>  will  he  a  strict uif  at  tlir  lr\cl  of  tin-  clavicles  and  a 
socoiid  aiul  lai,n<T  one  at  the  canliac  ciul  of  tlic  osophaffus.  Tlio  usual 
tiiflit  stricture  is  about  an  inch  louj;.  At  times  tlio  whole  lower  half 
of  the  esopliaijus  is  nairowed,  making  one  long  stricture.  Tia;  an 
tlior  met  this  condition  once  as  the  result  of  ulcerations  of  the  mouth, 
pharynx  and  esophagus  during  pni'unionia.  Partial  hand-like  stiic- 
turos  nuiy  jjrecede  and  guard  the  niMMiiui:  >>\'  \\\r  chief  stricture  Tlic 
esophageal  wall  al)ove  a  stricture  is  (lilate<l.  Tiiis  sac-like  iiuucli  m 
gages  the  end  of  a  l)ougie  and  keeps  it  from  linding  the  hiniin  of  tlie 
stricture  easily.  When,  however,  the  esophagus  is  examined  with  tlie 
esopliagoscope,  especially  if  a  tul>e  of  good  size  is  used,  the  hnmii  nf 
the  stricture  is  I'asily  made  to  come  opposite  the  end  of  tiie  tulie. 
(Fig.  17(5.) 

The  Diagnosis  and  Treatment  of  Esophageal  Strictures.— The  best 
method  of  determining  tiie  i)resence  of  an  esophageal  stricture  is  to 
]>ass  the  esophagoscoi)e.  The  larger  the  examining  tulie  the  easier  it 
is  to  find  the  constriction  and  to  make  the  lumen  of  the  stricture  center 
with  the  end  of  the  tube.  The  meie  presence  of  a  stricture  can  be  nuide 
out  with  a  small  tube  and  the  examination  carried  on  under  cocain 
anesthesia.  The  accuiate  mai»ping  out  of  a  stricture,  however,  and  its 
nmximuni  dilataticm  are  possilih'  only  under  genei'al  anesthesia.  For 
this  i-eason  tlu'  author  feels  that  time  is  wasted  in  examining  a  cica- 
tricial stricture  under  local  anesthesia.  Wln-ii.  therefore,  a  ])atient  is 
to  l)e  examined  for  a  cicatricial  stricture  he  shmdil  be  etlu'rized  and 
placed  on  the  examining  talile  with  tlie  head  hanging  oxer  tin'  I'dge 
and  as  large  a  tni)e  intnuhiced  as  can  be  made  to  pass  tlie  cricoid 
cartilage  easily.  I'nder  direct  vision  the  tnlie  is  carried  down  to 
the  stricture  and  the  lumen  of  the  stricture  made  to  correspond  with 
the  center  of  the  tube.  The  autliuiV  e\]jerience  has  been  that  this  is 
easy  to  accomjjlish.  Occasionally  ballooning  the  esophagus  with  air 
helps  to  find  the  opening  of  the  stricture.  After  the  dilatation  of  ;i 
-mall  stricture  has  been  begun  the  ballooning  is  an  easy  way  of  ki'ep- 
iiig  the  bl(M)d  out  of  the  mouth  of  the  stricture.  To  retiini,  after  the 
-tiicture  lia>  been  I'omihI  and  its  npciiinu  centeicd  at  the  (.'ud  of  the 
tube,  the  lumen  of  the  stricture  should  be  tesleil  with  an  idastic  bougie 
of  apjiropriate  size.  If  it  happens  that  the  lumen  measures  20  F.  or  is 
easily  dilatable  with  soft  bougies  up  to  this  calibre,  the  metal  dilator 
(Fig.  178)  is  carried  by  sight  through  the  stricture  and  the  dilating 
mechanism  exi>anded  until  marked  I'csistance  is  fell.  The  dilator  is 
kept  exjianded   for  two  or  three  miinites  and   then   closed.     After  a 


234 


OPEKATIVK    SriKIKlIY    OF   THK    XOSK,    TIIUOAT,    AND    EAU. 


short  interval  tlie  stricture  is  again  put  on  tlir  stretch.  By  coaxing 
tlie  (lihitation  a  marked  ji'ain  in  the  luiiicn  of  ihc  stricture  is  soon  at- 
tained. It  is  surjirisiiii;-  Imw  readily  even  old  >ti'ictni'cs  will  yield.  The 
author  so  far  has  not  found  it  necessary  to  cut  a  strictui-e  in  order  to 
make  dilatation  possible.  No  rule  can  be  given  as  to  how  fast  to  dilate 
or  how  nmcli.  lentil  more  data  have  been  accumulated  upon  this  ])oint 
the  opei'ator  nuist  use  liis  best  judgment.  The  aim  is  to  get  tlie  max- 
imum dilatation  so  that  a  good  sized  bougie  can  be  passed  easily  after 
the  examination.     In  a  bov  of  seven  vears  with  a  A^ear  old  corrosive 


'(■iimi;iiiimMiiinr;lnm»iiiiiir»iiiriiiiiiiiiriiiiii»rfriiiiriiiiimriiillinfin]riniiimi»[iiiiliiiiirnmmi[l»irir;miiiimTinimniirii 


Moslier's  moclianical  dilator,  -(vith  two  tips.     A,  tip  for  use  in  strictiiie 
of  the  esophagus;  B,  tip  with  larger  expansion  for  use  in  cardiospasm. 

stricture  which  would  not  admit  a  16  F.  bougie  without  ether  and  in 
whom  under  ether  a  20  F.  passed  tiniily,  I  was  content  with  a  dilatation 
to  34  F.  In  a  woman  of  forty  with  a  stricture  which  had  existed  since 
childhood  and  which  admitted  without  ether  a  number  20  F.  bougie 
with  difficulty,  the  dilatation  Avas  carried  carefully  up  to  42  F.  This 
was  sufficient  to  allow  the  passage  after  ether  of  a  32  F.  bougie.  The 
dilatation  was  subsequently  increased  by  the  weekly  passing  of  elastic 
bougies  up  to  36  F.     Rapid   dilatation   under  ether  saves  months  of 


Modified    Bunt's    olive-tipped    metal    bouRie.     This    instrument    is    used 
for  starting  the  dilatation  of  small  strictures  of  the  esophagus. 

time.    Experience  has  proved  that  ra])id  dilataticui  is  safe  if  carried  out 
with  ordinary  caution. 

In  the  treatment  of  strictures  in  which  the  lumen  is  so  small  that 
the  smallest  elastic  bougies  will  not  pass,  much  can  be  accomplished 
by  the  gentle  use  of  a  staff  carrying  small  metal  olives  (Fig.  179.)  With 
the  smallest  olive  an  eighth  or  a  quarter  of  an  inch  of  the  stricture  is 
picked  or  teased  open.  After  this  an  elastic  bougie  of  slightly  larger 
size  is  introduced  in  the  lioi)e  of  inci'easini;-  tin-  dilatation.     The  use  of 


I.AIiVXC.OSCOl'V.    nnoXl'IIOSCdl'V,    l.Snl'IIACdSCdl'N  ,    i;i(.  235 

tlic  iiictjil  .-live  should  lie  iiKist  ,<,niaril('(l.  All  tin-  while  llir  (iiktmIci- 
iim>l  lie  ciiusfinus  of  lln'  tnic  Jixis  oi"  thi-  csoiihatfus  hccaiisc  any  <h'via- 
lidii  from  the  in-oiirr  liiir  will  result  in  a  lU'i-roraliiMi  ami  lln-  iiinli.iMe 

.leatli  of  the  iiatienl.     In  Inn-  tiulit  strictures  it   i-  nnt    i es-aiy  thai 

the  himeii  be  restored  thnui-h  the  ulmle  leiiutli  "f  the  >ti-ietniv  at  tin' 
lirst  sittiuy-.  hocause  exi>erieuee  ha>  |iin\cd  tlial  it  i>  helt.T  in  siieh  cases 
to  oiH'ii  the  stomach  at  once  and  to  -el  the  patient  propeily  nourished 
heforc  very  tigld  ov  very  long  strictures  are  dilated.  Wiii'U  an  emaci- 
ated, half-starved  patient  i)resents  himself,  and  esiiecially  in  the  case 
of  children,  it  is  hettei-  snr-eiy  to  open  the  stomach  at  once  an<l  to 
restore  the  patient's  resistance  hy  rei'din-  iiet'ore  attemptinu-  the  dila- 
tation of  a  dillicull  stricture.  If  this  iiad  heen  done  there  is  no  huriy 
so  that  the  stricture  may  l)e  oi)ened  up  gradually. 

The  followin.s;-  histories  are  given  as  illustrations  of  topical  casi^s 
of  stricture: 

Case  NlUUber  1. — .\  l)oy  two  ye.-irs  old  drank  a  caiistir  soUilion  and  (im.  iii..ii;l,.s 
later  dovclo].i>d  marked  diHieulty  in  swallowing.  Milk  Ijeeame  his  only  food.  One  day 
tliis  would  stay  down,  the  next  the  [greater  jiart  of  the  milk  would  Ije  reginjiilated  soon 
after  it  was  swallowed.  A  number  Hi  F.  elastic  bougie  met  with  resistance  at  the  lower 
end  of  the  esophagus  and  would  not   enter  the  stomach. 

Under  ether  a  stricture  was  found  at  the  cardiac  end  of  the  esoiihagus,  and  a 
moderate  dilatation  of  the  esophagus  above  it.  The  stricture  proved  to  be  an  inch  long. 
It  dilated  readily  with  clastic  bougies  to  20  F.  I'rom  this  measurement  the  dilatation 
was  carried  to  32  F.  with  the  mechanical  dilator.  As  wa.-;  just  said  it  was  impos- 
sible to  pass  even  a  small  bougie  into  the  boy 's  stonuich  before  the  etherization  and 
dilatation,  but  afterwards  a  number  32  F.  could  be  introduced  easily.  The  family  phy- 
sician passed  a  number  .■;2  F.  bougie  once  a  week.  The  boy  soon  became  well  nour- 
ished again.  At  the  end  of  a  year  and  half  Ihc  motlu-r  of  the  clilM  reported  that  he  had 
no  dilliculty  in  swallowing. 

Case  Nimiber  2. — .\  woman  in  the  forties  gave  a  history  of  mariicd  dilliculty  in 
swallowing  for  two  months,  and  of  pain  in  the  epigastric  region.  She  was  moderately 
well  nourished  and  was  living  on  milk  and  soft  solids.  The  patient  stated  that  when  she 
was  a  small  child  a  playmate  offered  her  a  drink  of  vitriol.  Since  this  }ia|>pening  she 
had  had  a  moderate  and  stationary  amount  of  trouble  with  swallowing.  For  the  last 
month,  however,  the  trouble  had  suddenly  increased  and  she  had  begun  to  have  jiain  in 
the  region  of  the  stomach. 

A  number  20  F.  bougie  encountered  resistance  at  the  cardiac  end  of  the  esopha- 
gus and  entered  the  stomach  with  difliculty.  The  X-ray  showed  that  the  lower  half  of 
the  esophagus  was  narrowed. 

The  ether  examination  disclosed  a  stricture  at  the  le\el  of  the  cljivii-le.  Tln> 
lumen  of  this  was  about  .'50  F.  This  stricture  was  easily  dilated  with  tlie  mechanical 
dilator  so  that  it  permitted  the  passage  of  a  tube  measuring  half  an  inch.  A  second 
stricture  was  found  at  the  cardiac  end  of  the  esophagus.  The  second  and  lower  stric- 
ture was  dilated  with  clastic  bougies  up  to  22  F.  and  then  the  meclinnical  dilator  was 
introduced  and  the  stricture  stretched  slowly  and  at  intervals  of  a  few  miiuites  up  to 
a  linal  dilatation  of  42  K.  At  this  point  the  resistance  to  the  dilatation  became  extreme 
and   it  was  discontinued. 


23f)  OPF.IIATIVE    SriiCKItY    OF   THE    XOSE,    TIIItOAT,    AND    EAK. 


Fig.   180. 

Stricture  of  the  esophagus.  (Tracing  fro)ii  an  X-ray  phite,  retouched 
aud  reduced.) 

This  plate  was  taken  from  a  woman  forty  years  old.  At  the  age 
of  four  a  playmate  gave  her  a  drink  of  vitriol.  Since  then  she  has  always 
had  to  chew  her  food  very  !lne.  Vor  a  month  or  two  l)etore  she  came  for 
cxamiuatiou  she   had  been   living   on  liquids. 

A  Ko.  20  F.  elastic  bougie  entered  tlie  stoniacli  with  difficulty,  encoun- 
tering a  stricture  at  the  cardiac  end  of  the  esophagus.  The  X-ray  plate 
shows  that  the  lower  half  of  the  esophagus  is  narrowed.  Under  ether  a 
stricture  was  found  at  the  eud  of  the  clavicles  as  well  as  at  the  cardiac  end 
of  the  esophagus.  This  had  a  calibre  of  28  F.  The  upper  stricture  was 
dilated  first  with  the  mechanical  dilator  and  then  the  lower  one.  The  lower 
stricture  was   dilated   at  the   first  e.xaminatiou  from  20  F.  to  .'!2  F. 


I.AIIVNCOSCdl'V.    KKdNlllOSrol'V,    KSdl'l  lACOSCOI'V,    KTC.  _■>( 

Tlic  inslriiiiu'iilMliim  wns  not  followi'il  liy  nny  rise  in  t("iii|uMnliirc',  liiit  I'm 
(lays  tlipre  was  an  inoroasc  of  tlic  c'l'ii;nstrii'  pain,  and  for  lliico  or  four  il;i.vs  ilir 
ability  to  swallow  was  Ipssi-iu'il.  Hy  tlic  cnil  of  tlip  wcolt  tlio  pain  \u\t\  ilisaiiprari'd  ami 
the  pationt  was  swallowinj;  lii-tliT  than  lu-foro  the  oporntion.  At  this  time  a  niinilicr 
30  F.  olasti<-  lioiigio  passed  without  diflirulty.  l'"or  alioni  a  year  afterwards  bougies  were 
passed    on    the    avera;;e   of    every    two    «.■  '  l'..  iiv   :i    luinilier   S(i  F.   jiasses   willioiit    dilli- 

dty  and  the  woiuan  eats  everythia;;. 

This  caso  slimvs  lliat  wlu'iv  tlicic  air  Iwu  <>r  iiiuir  constriclioiis  llio 
bougie  liK-att'S  only  tlu'  snialltT  oiu'.  I'lmn  tin-  ai:i'  nf  the  lower  strietiii-e 
and  from  its  lirnmoss  at  the  bofriimini;  nf  the  <lil.Jatiiiii  llic  author  was 
of  tlie  oi)iiiioii  tliat  it  avouM  liavc  to  ln'  cut  lict'ipic  any  iiicrca-c  ol" 
its  luiiii'ii  eoiilil  he  aeeoiiiphshcil.  A  littlr  pal  iriicc  in  tin'  nsi'  nf  the 
meehanieal  dihitor,  however,  soon  proved  that  this  supposition,  Imw- 
cver  iiaturai.  was  wrong.  This  ease  shows,  therefore,  tlie  pos'sil)ilities 
of  rajiiil  dihitation  even  in  old  strietnres.  It  shows  fnrtiier.  that  the 
liisniuth  X-ray  exainiiiati(ni  reveals  only  the  npjx'r  stricture  ami  .<;ives  a 
false  iinprcssidii  n\'  the  cnniiitidn  nl'  the  i's(ipliai;ns  lirlnw  the  lii'st  nar- 
rowing. 

Case  Number  3. — Two  years  ajjo  a  boy  of  five  was  brought  to  the  Massai-liuselts 
General  Hosiiital  starving  from  the  effects  of  a  corrosive  stricture  of  the  esophagus.  His 
stomach  was  opened  under  cocain  anesthesia,  a  tube  inserted,  and  the  boy  brought  back 
to  proper  nourishment  and  resistance .  by  stomach  feeding.  Then  attempts  were  made  to 
|)ass  the  stricture  from  above  by  introducing  bougies  and  by  having  the  boy  swal'.ow  a 
string  to  act  as  a  guide  for  a  perforate<l  olive  on  a  metal  staff.  These  attempts  failed. 
The  attempt  also  failed  when  the  stricture  was  attacked  from  lielow  through  the  gastric 
fistula  by  means  of  a  cystoscope. 

A  year  later  the  boy  again  entered  the  hospital.  He  was  slill  fed  through  a  tube 
in  the  gastric  tistula.  He  was  at  this  time  the  picture  of  health,  fat  ami  jiink.  The 
X-ray  revealed  a  constriction  of  the  esophagus  beginning  at  the  level  of  the  nipples  and 
continuing  on  to  the  stomach.  Above  the  stricture  the  esophagus  was  much  dilated. 
Examination   with   chemicals    proved   that   nothing   could    reach   the   stomach. 

Dr.  S.  .1.  Mixter,  to  whose  wards  the  b'\v  was  admitted,  kindly  asked  the  author  to 
see  the  case.  The  examination  umler  ether  showed  that  the  up|>er  half  of  the  esophagus 
wiis  dilated  and  that  llie  stricture  began  as  the  Xray  had  sliowii.  at  the  level  of  the 
.nipples.  The  lumen  of  the  esophagus  was  reduced  to  a  central  opening  about  one-six- 
teenth of  an  inch  in  diameter.  .V  filiform  bougie  would  just  engage  in  this  and  then 
would  enter  no  farther.  Having  gained  this  information  from  above  an  attempt  was 
made  to  pass  the  stricture  from  below  tliroiigh  the  gastric  fistula,  by  using  a  small 
short  bronchoscope.  This  was  not  successful.  Then  Dr.  Coidiilge  took  the  brondio- 
scope  and  worked  from  below  while  the  author  worked  in  the  esophagus  from  above 
using  a  small  esophagoscope.  This  double  attack  on  tiie  stricture  made  no  gain  and  the 
manipulations  from  below  were  discontinued.  The  author  .soon  fo\ind  that  on  using 
the  small  metal  olives  on  the  end  of  a  metal  staff  tlie  lumen  of  the  stricture  could  be 
entered  a  short  distance,  perhaps  an  eighth  of  an  inch.  ICncouraged  by  this  he  persisted 
in  the  use  of  the  metal  olive  using  first  the  metal  olive  and  then  a  small  ela.slic  bougie 
of  slightly  larger  size.  The  result  of  the  first  day's  work  was  the  ungluing  of  about 
an  inch   of  the  stricture.     Xo  reaction   followed   the  manipulations. 

Two  weeks  later  the  lioy  was  i-tlierized  again  and  the  same  manipulations  repeated. 
A   second   gain   of  nearly   an   inch   was   secured.     During   this   sc'i'oiid    session   at    the   stric- 


238  OPEKATIVK   SlKCKilV   OF   TJIE   NOSE,   TIIKOAT,   AND   EAK. 

ture  the  ballooning  allaclinient  was  employed  from  time  to  time  in  onlei-  to  clear  the 
blood  from  the  lumen  of  the  stricture  and  in  the  hope  that  .some  of  the  air  might  find 
its  way  into  the  stomach.  Air  finally  did  enter  the  .stomach  and  could  be  detected  com- 
ing out  of  the  gastric  fistula.  This  haii|iruiii;4-  was  must  comfortiu};-  and  encouraging. 
It  proved  that  the  metal  tjlive  was  following  the  riglit  line  ami  that  tlic  lower  inch  of 
the  stricture  was  pervious  to  air.  Without  the  confidence  which  this  finding  gave  the 
author  might  have  given  up  the  attempt  to  pick  apart  so  long  a  stricture,  because  if  the 
line  of  the  stricture  was  not  adhered  to  closely  the  olive  would  perforate  the  walls  of 
the  esophagus  and  convert  the  case  into  a  tragedy.  After  a  second  interval  of  rest,  about 
two  weeks,  the  boy  was  etherized  for  the  third  time.  The  gain  made  at  the  other  exam- 
inations was  found  to  be  retained.  Air  still  could  be  forced  into  the  stomach,  and  after 
a  little  manipulation  the  olive  also  entered.  This  wa.s  followed  by  soft  bougies  until 
the  lumeu  of  the  .stricture  was  increased  to  20  F.  The  mechanical  dilator  was  then 
put  in  and  expanded  at  intervals  to  28  F.  The  umnijiulatious  ended  by  carrying  into 
the  stomach  a  thread  and  bringing  the  ui>i)er  end  of  tliis  out  of  the  numth  and  fixing 
it  over  the  ear. 

Three  or  four  days  later  the  perforated  metal  olive  on  a  long  staff  was  carried 
down  on  the  thread  into  the  stomach.  The  boy  began  to  drink  milk.  It  was  soon  pos- 
sible to  pass  the  olive  through  the  stricture  mthout  using  the  string  as  a  guide.  This 
was  fortunate  because  the  thread  was  vomited  after  a  few  days.  The  further  treat- 
ment of  the  case  consisted  in  passing  larger  and  larger  olives  at  appropi'iate  intervals 
until  a  final  dilatation  of  ?,6  F.  was  reached. 

In  this  case  an  absolute  stricture  three  inches  long  and  a  year  old 
was  opened  up  piecemeal  with  a  final  lumen  of  36°  F.  The  previous 
treatment  of  the  case  along  general  surgical  lines  had  faih^l.  This 
fortunate  case,  therefore,  shows  in  a  striking  mannei-  the  possibilities 
of  the  treatment  of  strictures  by  tlie  esophagoscojie  and  by  apjiropriate 
insti-umeiits  used  through  it. 

The  Use  of  a  Thread  as  a  Guide  in  Esophageal  Strictures. — The 
procedure  of  having  the  patient  swallow  a  thread  was  a  great  advance 
iu  the  general  surgical  treatment  of  strictures  of  the  esophagus.  It  is 
mentioned  in  coimection  Avith  the  use  of  tlie  esophagoscope  because 
occasionally  advantage  may  be  taken  of  this  procedure  in  connection 
witli  the  use  of  tlie  tube.  The  swallowed  thi'ead  may  be  used  to  guide 
the  esopliagoscope  to  the  lumen  of  the  stricture,  altliough  as  the  oper- 
ator becomes  accustomed  to  the  use  of  the  esophagoscope  and  resorts 
to  ballooning,  he  will  find  the  swallowed  thread  less  and  less  necessary. 
The  chief  use  of  tlie  thread  is  its  employment  as  a  guide  for  the  metal 
olive  after  the  rapid  dilatation.  When  used  in  this  way  a  yard  or  two 
of  stout  wa.xed  thread  is  wrapped  about  a  small  button  and  tlie  button 
is  carried  into  the  stomach  through  the  tube  (hiiing  the  examination 
and  after  the  stretching.  The  upper  end  of  the  thread  is  brought  out 
of  tlie  mouth  and  fastened  over  the  ear.  Generally  the  use  of  the  thread 
as  a  guide  for  the  metal  olive  and  its  staff  is  necessary  for  a  few  days 
only,  because  the  operator  soon  becomes  orientated  in  regard  to  the 
lumen  of  the  strictui-e  and  finds  that  the  metal  staff  allows  hiin  to  turn 


KAivVXciosciti'v.  ltl:(l^■(•ll()S('lll■^ .  r.soi'iiAiiosi'tn'v,  v.rc. 


23!) 


the    (ilivr    ill    .lirrclcllt    (rnccliuli>    ;in.|    I<i    piolir    I'm-    lllr    (.lichillii-    (if    tllf 
si  rirllirr  --lIccr^^rilllN  . 

The  Spiral  Staff  for  Carrying  Olives.  I'ln'  |Mii|i«.sr  of  iiitnidiiciiii,' 
till'  iiut.il  ()li\c  .-iiiil  its  stall'  is  that  dlivcs  i>l'  iiicrcasiiiii  si/.r  may  he 
passt'il  uii  till'  iiu'tal  siial't  until  the  tliiatatiun  (tf  tlii'  stricture  is  such  tiiat 
the  passage  of  elastic  hougies  is  i)ossihle.  (Fig.  LS-"!. )  lusieail  of  forc- 
ing tiio  ))erforate»i  olive  ddwn  the  stall"  and  thr<ingh  tlie  stricture  hy  a 
second  stall"  carrying  a  liug  [ihiceil  at   liizht  angles  to  the  shall,  hetter 


Fit;.    ISl. 
Haiullo  anil  sfafV  ol'  I'lummcr 's  csopliaiii'al  whaleljoiii'  tioiigic. 


Wlialolionc  staff  of  Pluninier's  osopliajical  boujific  fitted  witli  two  olives. 
The  first  olive  is  pierced  to  run  on  a  thread.  The  olives  are  made  in 
graduated  sizes. 


(^      i^      {^Td      C^i     c^ 

CD     O     O*     (^    (^    ^^ 

F\g.  isn. 

A.  Metal  stafT  larryinj;  a  iierforated  olive  at  the  tip  (Mixter) ;  H, 
•Special  wire  carrier  (Mosher),  on  which  various  sizes  of  olives  are 
screweil;    (",    Graduated    olives. 

reMilt>  can  lie  (pl)taiiied  Ky  (  ni|ih>ying  the  >)iii-a!  wire  carrier.  The  llex- 
iiile  |iu>her  Imckh's  aw  ay  I  Vdiii  the  line  of  1  he  iiiaiu  si  all',  aud  mi  at  times 
refuses  to  push  a  .-^nug  olive  thidugh  liie  stricluri'.  Tiie  spiral  w  ire  car- 
rier, on  the  otlier  lumd,  lings  the  guiding  staff  clot^ely  and  gives  a  direct 
push  nn  tlic  nlive.  When  the  (dive  is  in  p(isiti(ni  against  the  stricture  if 
liie  (iperatdr  puts  his  linger  in  tiie  palieiil  ">  piiaryiix  aud  pre>>es  ddwn- 
ward  on  the  sjiiral  staff,  he  can  exert  great  pressure  on  tiie  olive  below. 
In  fact,  tiie  antiior  found  tluit  tliis  method  of  forcing  an  olive  througli  a 


24(1 


OPERATIVK    SUKCKUV    OK   THE    MISK,    TUllOAT,    AND   EAR. 


sti'icliii-i'  was  s<i  iiowcrl'iil  lliat  care  was  iicccssarv  oi-  the  strctcliin<;'  of 
the  strictufi'  w'Dulil  lie  tiMi  i-a|ii(l  ami  rnllnwcil  liy  a  I'cactioii.  A  scries 
of  olives  of  iiicreasiui^-  sizes  enmcs  witli  the  spiral  stall'.  An  olix-e  of 
any  size  can  be  extemporized.  1  n  the  case  of  the  boy  (Case  :!,  page  2."!7) 
an  olive  of  the  desired  size  not  bein<^'  at  hand,  an  olive  was  wonnd  on 
the  start'  by  nsing  coarse  snr,a,-ical  silk.  Tlie  silk  was  given  a  smooth 
coating  by  smearing  it  with  iiKiihding  (■(unpoiuid,  such  as  dentists  use 
for  taking  impressions  of  the  teeth.  The  spiral  staff  permits  two  or 
more  olives  of  increasing  size  to  be  put  on  at  once.  These  may  be  placed 
at  intervals  after  the  fashion  of  Bunt's  bougie.     (Fig.  179.) 

The  After-care  of  Stricture  of  the  Esophagus. —  When  a  stricture  of 
the  esophagus  lias  been  dilated  sufficiently  to  permit  the  ]iatient  to 
swallow  readily,  bougies  of  maximum  size  must  be  passed  at  intervals 
of  a  week  or  two  or  monthly,  for  months  or  years.  Not  iiii'iciiuciitly 
adult  patients  learn  to  pass  the  bougie  upon  themselves. 


s^U^^JO 


Pig.   184. 
Mosher's  two-bladoil  Jilator  witli  sliiliiig-  knife  for  cutting  strictures  of  the  esophtigu^i 


Spastic  Stenosis  of  the  Esophagus. 

Esophagospasm  (Esophagismus). — Esophagospasm  is  an  excessive 
irritabilily  of  the  esophagus.  It  prevents  the  introduction  of  the  esopli- 
agoscope  under  local  anesthesia.  Under  general  anesthesia,  however, 
the  esophagoscope  passes  easily.  On  examination  the  esophagus  is 
found  to  be  normal,  or  if  any  lesion  is  discovered  it  is  almost  always 
a  simple  ulceration.  Esophagospasm  is  the  underlying  condition  in 
globus  hystericus.  It  sliould  be  remembered  that  a  diagnosis  of  globus 
hystericus  is  made  less  and  less  often  since  the  use  of  the  esophago- 
scope has  become  common.  On  this  account  the  diagnosis  should  always 
be  looked  upon  with  suspicion. 

The  treatment  of  esophagospasm  is  to  pass  the  eso])hagoscope 
under  ether  anesthesia  and  to  treat  any  ulceration  present  with  some 
mild  caustic.  If  the  esophageal  wall  proves  to  be  normal  the  regular 
passing  of  elastic  bougies  in  time  establishes  tolerance  and  does  away 
with  the  sensitiveness  of  the  esophagus. 


T..\i:vN"(;i)si'(>i'v,  UKdNciinscniM'.  l•■.sl(l•ll.\l;l>s(■(ll•^ .  i/rc. 


L'41 


Cardiospasm.  ('iiiirHis|)asiii  is  the  ii;iiiir  a|i|p|ic'i|  tn  a  <-(iii(liii(iii  of 
spasnioilii'  closuiv  ol"  tin*  csoiilia.n'us  a1  the  carcli.-u'  ii|iriiiiiL;  n\'  tlir  stoiii- 
acli.  The  iiaiuo.  liowovcr.  is  used  in  i-ouiu'ctioii  with  spasiiiodic  closure 
of  the  esophagus  at  auy  other  point.  This  eonditiou  is  one  of  the  most 
important  i>athoKi,uie  alVectious  of  the  e--oiihni:us.  Its  ctiohjiry  is  still 
ohseure.    .Taekson  holds  tiiat  the  cai'lia  i>  not  a  true  -iiliiiicter  in  siiite 


Fig.    1S5. 
Cardiospasm.    Retoiiclied  tracing  from  an  -X-ray  plalo.    The  osoiiliagiis 
is  filled  witli  bismuth  gruel,  and  is  narrowed  to  a  very  small  lumen.    Alxive 
the   narrowing  it   is  dilated.      (Author's  case.) 


nf  tile  circular  liliers  nl'  II  \  it  I,  Inn  iiiaintnin-  t  li;it  t  iic  hiatus  is  an  actual 
spliiiictei-aiid  acts  a>  nnc  in  .•;iidiu>|ia-iii  iliciv  aiv  t  \vn  i-hief  I'eatui-es, 
S|)asm  of  the  eardia  and  dilataliun  ,,r  tlic  c>(,|i|ia-ii>.  In  the  majority  of 
the  eases  there  is  atony  of  the  inuscular  wall  as  well.  The  conditions 
which  are  responsilile  for  these  chaii-cs  have  heen  hehl  by  various 
writers  to  l)e  a  coii,<,'eiiilal  derecl.  a  piiniary  neurosis,  or  an  esopha.y-itis. 
In  some  cases  the  atony  i^  piimaiy  lo  the  spasm  an<l  dilatation,  in  others 


242 


OPEKATivK  sri;(;i;i;v  (ir  •nil-:  xosio,  throat,  and  kai;. 


the  spasm  comos  first.  Lerclie  maintains  tliat  an  attempt  should  be 
made  from  the  (dinical  histories  to  divide  eases  into  tiie  two  cdasses  just 
mentioned.  Gottstein  gives  the  following  classification:  (A)  Cases  in 
which  excessive  s])astic  muscular  contractions  take  place.  (B)  Cases 
in  which  the  contractility  of  tlie  muscles  is  weakened  or  lost.  (1) 
Cases  are  classed  as  idiopathic  in  which  no  organic  lesion  can  he  dem- 
onstrated, (2)  as  secondary  or  symptomatic  when  due  to  some  anatom- 
ic alteration  as  ulcer  or  cancer. 

ruder  class  A  (excessive  muscuhir  coiil inaction)  are  grouped: 
eso])hagos])asni  and  cardiospasm.  The  hrsl  involves  the  esophagus 
proper  and  the  second  only  the  cardia.  Cardiospasm  may  be  acute  or 
chronic. 

Leichtenstern  defines  cardiospasm  as  a  pathologic  exaggeration  of 
a  physiologic  phenomenon,  due  to  abnormal  innervation  of  the  cardia. 
It  produces  an  habitual,  non-permanent,  spastic  closure  of  the  cardia. 
This  is  greater  than  normal,  lasts  a  long  time,  and  occurs  especially 
after  meals.  It  is  not  known  whether  the  condition  is  caused  by  a  fail- 
ure of  the  inhiliitory  nerve  fibers  which  control  the  normal  tonus  of 
the  cardia  or  to  some  irritation  which  causes  an  increased  tonus  in  the 
contraction  fibers. 

Frequency  of  Cardiospasm. — Both  sexes  are  affected  equally.  The 
majority  of  the  cases  occur  between  the  ages  of  twenty  and  forty,  but 
cases  have  been  reported  in  which  the  i)atients  were  eight  and  foTir 
years  old.    The  latter  case  was  one  of  acute  cardiospasm. 

Anatomic  Con.sideeations. — According  to  Rumpel  the  capacity  of 
the  esophagus  varies  between  40  cc.  and  80  cc  but  even  150  cc.  may  be 
considered  within  physiologic  limits.  The  position  of  the  cardia 
changes  with  age.  In  the  infant  it  is  found  at  the  level  of  the  eighth 
dorsal  vertebra  whereas  in  the  aged  it  may  be  placed  as  low  as  the 
twelfth  dorsal  vertebra.  In  the  neck  the  esophagus  is  closed,  but  in 
the  chest  it  is  open  and  contains  air.  Mikulicz  found  that  the  intraeso- 
phageal  pressure  during  rest  was  a  little  below  that  of  the  atmosphere. 
By  quiet  inspiration  the  pressure  is  lowered  to  9  cm.  water  pressure 
and  by  forced  inspiration  to  20  cm.  below.  On  quiet  exjiiration  the 
pressure  rises  to  10  cm.  water  pressure,  and  by  forced  expiration  to 
20  cm.  Coughing  may  raise  the  pressure  to  60,  80,  or  even  160  mm. 
mercury.  On  swallowing  the  pressure  varies  between  0.80  and  22  cm. 
water.  The  normal  esophagus  opens  easily  wdthout  the  aid  of  swal- 
lowing for  tlie  passage  of  fluids  and  gases  from  the  esophagus  into  the 
stomach,  but  opens  with  difficulty  for  their  passage  in  the  reverse  di- 
rection. The  pressure  necessary  to  open  the  cardia  amounts  to  a  frac- 
tion of  the  pressure  of  a  column  of  water  filling  the  thor;i,/ic  portion 


LAKVxcnsnu'Y.  mtoNi-iioscoi'v,  ksoimiac.oscoi'v,  i:tc. 


24:^ 


of  tlio  i>so|tlia,iiUs.  W'lu'ii  initatiiin'  lluiils  siicli  ;is  very  Imt  i<v  cnld 
liiiuids  oi-  carbonizctl  driuks  arc  taken  the  incssiirf  iiucessaiy  to  fm-c-o 
tlieiii  (low  u  is  higher. 

If  the  resistance  of  tlie  <'ai(lia  is  iiK-rcascd.  a  part  id'  tin 
lowed  will  remain  in  tlif  csojili 
agiis.  Sujinose  tiiat  in  oidir  to 
effeet  automatie  opening  of  tlif 
eardia  under  normal  conditions 
a  pressure  of  1  L'  ciii.  watn-  pi-es- 
sure  is  neci'ssary.  In  tiiis  case 
the  excess  of  fluid  over  IL'  cm. 
woulil  (low  into  the  stomacli  liy 
its  wi'ight.  leaving  lichind  a  111 
cm.  cohunn  of  Huid.  The  next  act 
of  swallowing  which  corresponds 
to  ahout  12  cm.  water  pressure 
would  carry  this  into  the  stmn- 
ach.  If  the  resistance  (d'  the  car- 
ilia  corresponds  to  24  cm.  watci' 
pressure,  there  will  be  left  a  col- 
unm  of  12  cm.  at  the  end  of  tlic 
act  of  swallow  ini;-.  if  the  I'csist- 
ance  of  the  eardia  is  still  higher 
(mly  so  much  llnid  will  pass  the 
eardia  as  is  pressed  down  by  tin- 
muscles  of  the  pharynx.  Tlic 
esojihagus  itself  can  overcome  the 
resistance  of  the  eardia  only  by 
energetic  contraction.  In  a  nor- 
mal esophagus  the  effect  n\'  tins 
increased  pressure  on  the  esoph 
agus  is  small  but  as  soon  as  the 
esophagus  becomes  dilated  the 
(dTect  of  the  increased  pressure 
which  is  necessary  to  force  food 
tlirf)Ugh  the  unyielding  eardia 
is  to  make  the  esophagus  di- 
late more  ami  more.  Stagnating 
food  leads  to  changes  in  the  esophageal  wall  which  further  weaken  it. 

Mikulicz  used  the  esopliageal  f)ressin-e  dniiiig  swallowing  as  an 
indication  of  the  contractile  powei-  of  the  esoi)hageal  musidcs.  Tie 
therefore  measures  this  pressure.  Lerclie  has  devised  an  apparatus 
for  doing  this.     (Fig.  ISG.) 


Aiip:\ratiis 
After   I.rnl. 


Fig.    186. 
for      diliitiiiK      tlic      cardm. 


244  oi'i-:i:ATi\ii  srR(iKi;v  ok  the  xose,  throat,  a.nd  ear. 

The  Symptoms  ok  Cardiospasm. — 'I'lic  two  cliid'  syiiiptoms  of  car- 
diospasm arc  (lifliculty  in  getting  fooil  into  the  stomacli.  and  ric(|iicnt 
regui'gitation.  Often  the  patient  has  a  trouhlcsoinc  cough  at  night,  or 
is  awakened  by  food  running  barl\  into  tlic  pharynx  and  into  the  nose. 
If  the  condition  has  existed  for  some  time  the  patient  is  much  emaciated. 

Examixation. — The  history  of  the  patient  should  exclude  syphilis, 
and  till'  swallowing  of  caustics  or  foreign  bodies.  In  the  general  phys- 
ical examination  of  the  pressure  from  an  aneurism,  a  goitre,  or  a  tumor 
in  the  mediastinum  should  be  constantly  borne  in  mind.  The  csoplia- 
geal  examination  should  be  ruled  out  in  the  presence  of  nlcers.  and  of 
malignant  or  benign  growths.  It  must  be  remembered  that  a  large 
or  a  h>w  seated  diverticnlnm  of  the  eso])liagus  may  be  present. 

Alucli  light  is  often  thrown  on  a  case  by  filling  the  esophagus  with 
bismuth  and  then  taking  an  X-ray  plate. 

The  Examhiatiov  r^rler  Local  Auesthesia. — A  large  sized  elastic 
bougie  is  intro(hiccd  into  the  esophagus  and  tlie  distance  of  the  obstruc- 
tion from  the  incisor  teeth  is  found.  In  a  case  of  cardiospasm  the 
bougie  will  occasionally  pass  through  the  cardia  easily  or  on  gentle 
pressure,  at  other  times  much  pressure  is  needed  to  force  it  through. 
The  esophagus  is  washed  out  and  the  throat  cocainized.  Then  the  eso- 
phagoscope  is  passed  and  a  careful  examination  is  nuule  of  the  esoph- 
agus. The  condition  of  the  mucosa  and  of  the  esophageal  walls  is 
noted.  It  slioulil  be  ascertained  whetlier  the  walls  are  firm  or  flaccid 
and  whether  tlie  esophagus  is  normal  in  size  or  dilated.  Ulcerations, 
diverticulum  and  new  growths  are  excluded.  AVhen  the  tube  reaches  a 
proper  depth  tlie  cardia  is  seen  as  a  slit  with  the  long  diameter  lying 
obliquely  from  the  right  posteriorly  to  the  left  anteriorly.  This  is  not 
the  cardia  strictly  speaking,  but  the  hiatvis  of  the  esophagus,  though 
many  writers  use  this  name  for  the  constriction  of  the  esophagus  at 
the  ])oint  where  it  goes  tlirough  the  diai)hragni.  Tlie  liiatus  ap])ears 
either  as  a  slit  or  as  a  rosette.  In  s])asm  it  is  usually  like  a  rosette.  It 
has  been  compared  to  the  montli  of  the  cervix  uteri.  (Fig.  168.)  The 
eso))hagoscope  cannot  be  passed  in  cases  of  cardiospasm  into  the  stom- 
ach without  first  cocainizing  the  hiatus.  As  soon  as  the  hiatus  gives 
way  the  tube  is  carried  into  the  stomach  and  then  withdrawn.  On  the 
withdrawal  the  esophagus  is  examined  again  in  order  to  confirm  the 
negative  findings. 

In  a  complete  examination  the  next  step  is  to  determine  the 
capacity  of  the  esophagus.  An  esophagometer  is  xised  for  this  purpose. 
Lerche  has  devised  an  instrmnent  of  this  nature.  It  consists  of  a  rub- 
ber bag  which  is  inserted  into  the  esophagus  and  tlieii  tilled  with  air. 
A  recording  mechanism  reyisters  the  amount  of  air  necessarv  to  make 


I.Al:v^■(;(lS(•(n■^•,  iii;oxciinsc(ii'\ .   i:sni'ii.\(iiiS('or\'.  irrc.  L'4.) 

tlk'  \>i\'j;  assiiinc  tlii'  saiiif  (lilii(;itii>ii  .•iinl  sluipc  iis  llic  (•s(>])liii.i;iis.  An 
X-ray  i)ictur«'  may  l>f  taUni  with  the  liau  in  jilarc  Tliis  will  iloiiioii- 
stratc  tile  sliapc  t>\'  the  (liiatimi  iiioif  sli:iiiil>    than  tlic  I)isinu11i  <;i-iicl. 

'PiiK  Thkatmknt  <ii'  ('ahi»I()si'.\sm. — Thr  ticatnicni  nl'  caiilidspasni 
consists  ill  strctchiiiif  tlu"  hiatus  of  tlu'  ('soi)lia,i;ws.  This  can  ho  of- 
iVctod  with  a  itlial)lc  dihitor  like  a  i  iiIjIkt  baii",  or  witii  an  instrument 
moiU'k'tl  on  llic  iprinciplc  of  tlic  nnthial  dilator.  TIk-  ruhbi-r  ba,u:.s 
are  yvnorally  used  undor  local  aiu'stlicsia.  'riu'  ajiparatus  used  l)y 
liorclio  is  shown  in  Pisj;.  18(j.  It  consists  of  a  stonuich  tube  the  end  of 
which  is  covered  witli  a  sausago-sha]ieil  silk  liaii'  10  I'J  cm.  liuii;'.  Tiie 
bag  is  distended  b\-  eomiectini''  the  aiipaiatus  witli  a  water  faucet. 
A  secondary  mechanism  regulates  the  amount  and  the  pressure  of 
the  "water  and  so  the  pressure  exerted  by  the  bag  when  it  is  in  place. 

The  use  of  bougies  in  pronounced  cases  of  carilios])asm  for  dilating 
the  hiatus  does  not  give  good  results. 

(lumprecht  has  stated  that  the  maxinaun  dilatation  to  which  the 
normal  cardia  can  be  stretched  is  respectively  3  cm.  and  3.5  cm.  Scheiber 
found  that  the  normal  cardia  from  the  stomach  side  could  withstand 
a  ]tressure  of  350  grams  for  a  few  seconds.  Strauss  distended  the 
lubber  bag  with  air  and  had  iiis  ap|)aratus  so  regulated  that  a  pres- 
sure of  not  more  than  250  cm.  of  meixnii'v  coidd  lie  brought  u]ion  the 
cardia.  Jacobs  using  a  mechanical  dilator  fashioned  on  the  ])lan  of 
(he  uretiiral  dilator  stretched  the  cardia  to  a  diameter  of  3.5  cm. 
Mikulicz  working  from  witliin  the  stomach  stretclied  the  ear<]ia  to 
a  diameter  of  7  cm. 

'The  Treatment  of  Cardiospasm  Under  Ether. — An  examination 
under  ether  is  much  easier  for  the  i>atient.  The  stretciiing  of  tiic 
cardia  with  the  mechanical  dilator  is  nmch  simjilcr  than  the  use  of  the 
iubl)er  bags.  There  is  oni'  diawl)ack,  howe\ci-,  tn  the  examination 
mider  ether.  All  spasm  of  the  esophagus  is  done  away  with  and  the 
cardia  itself  nuiy  so  be  relaxed  that  unless  the  examiner  bears  this  fact 
in  mind  he  may  feel  that  lie  has  not  found  the  cause  of  the  condition  for 
which  the  examination  is  undertaken.  After  the  ether  examination  in 
cases  of  cardiospasm  and  the  dilatation  of  the  cardia  the  author  has 
been  in  the  habit  of  leaving  a  tlireail  in  the  esophagus  and  in  the  stom- 
ach ami  of  jjassing  the  olive  tijjped  staff  on  the  lliiead  I'or  a  few  days 
until  it  was  possible  lo  i)ass  the  staff  nnguided.  ( )n  tlie  staff  metal 
olives  of  increasing  size  are  jiassed  for  a  time  and  then  the  unguiiled 
clastic  bougie.  Finally  the  patient  is  taugiit  to  i)ass  the  bougie  for  him- 
self. This  he  does  at  intervals  according  to  the  ])ersistence  of  the 
spasm. 

The  relief  of  carilios])asni  is  easily  broiighi  ai)out.  The  ])aiient's 
s>ini)toms  lessen  almost   immeiliately.     Measuii-ments   show   tinit   the 


246 


OPERATIVK    SrUdEIlV    OF    TlIK    XOSK,    TliltOAT,    AND    EAR. 


esopliaiius  soon  contracts  unless  llici'c  has  Ixn-n  cxtcnsixe  weakening 
of  the  esojiliageal  Avails.  Cases  of  lliis  kiml,  altliou^h  they  ol)tain 
niarki'cl  relief  from  st  I'etchiiii;-  of  the  cardia,  iialiu-ally  still  have  a 
certain  amount  t)f  residual  tr(jul)le  on  account  of  the  slowness  with 
which    food   passes  the  weakened   esoplia,iius.      Cases   of  cardiospasm 


Cardiospasm.    Ki-oin  a  iirint  of  an  X-ray  plate,  showing  a  dilated  esojili- 
agus.     The  esophagus  narrows  to  a  point  in  the  shadow  of  the  iliaphragni. 
(Plate  b.y  Dr.  F.  H.  AVilliams.) 


I,Al;v^■(;(lS(•()I'^•,  iiKoxriioscoi'v.  losoniAUdsroi'v,  irrc.  24V 

ail'  aiiiuii^-  tile  iiio>t  (liainatic  of  siir;;i'ry.  Tlu'  follow  iii^-  case  is  an 
example:  A  yoiinii'  woman  liad  lircn  ro.srni'.ifitatiii.si:  her  food  for  llftoeii 
years.  Slie  wh'mI  from  ]ili>>-ici;m  lo  pliysiciaii.  Slie  was  conslaiitly 
eatin.ii"  but  was  always  limiui'v,  ami  c-niisniiu'ii  (•noui;li  foo<l  foi'  two  oi- 
llii-('c  i)('o|)li'  l)iit  conliniKilly  \\a>tci|  away.  Wlicii  slic  lay  down,  I'ocxi 
reiiurnitated  into  lu-i-  mouili  or  her  nose.  This  and  a  constant  eon.i'li 
kejjt  her  awake.  In  a  slu)rt  ether  examination  histinn'  alioiil  the  same 
number  of  minutes  as  she  liad  been  ill  yeai's  the  cause  of  tlic  trouble 
wa-;  discovered  and  praetieally  cured.     (Fi,ii:.  1^7.) 

Phrenospasm. — Phrenospasm  is  the  name  api)lie<l  by  .Tackson  to 
spasmodic  closure  of  the  esoiiha.u'us  at  the  hiatus.  This  condition  i- 
frequently  seen  in  passinjj,-  the  eso])haf;oscope  w  ithout  anesthesia.  I''re 
quently  the  esophas'oseope  is  hu^-f;ed  so  tiuhtly  that  the  subphrenic 
];ortion  of  the  e.<opha£>'Us  cannot  be  enleted.  I'nder  ucneial  anesthesia 
the  s])asmodie  closure  of  the  hiatus  di>ai>|>ears.  This  characteristic 
disa])])earance  of  the  siiasni  together  with  a  normal  mucosa  establishes 
the  diagnosis  of  ]ihrenosjiasm.  Almost  invariably  the  <>sophafius  is 
dilated  above  the  hiatus. 

.Jackson  mak"es  a  clear  distinction  between  spasm  of  the  cai'dia 
and  sjiasm  of  the  hiatus.  Many  authors  do  not,  but  >peak  of  sjiasm 
of  the  cardia  when  in  reality  they  mean  sjiasni  of  the  inatus.  Then 
again  the  tei'ui  s])asm  of  the  cardia  is  u>eil  to  mean  s))asm  either  at 
the  cardia  or  at  the  hiatus.     Jackson's  termiuo|oi;y  h'ads  to  cK'arness. 

Benign  New  Growths  of  the  Esophagrus. 

Benign  neoplasms  of  the  esophagus  occnr  but  are  imt  comuKUi. 
AVhen  it  becomes  the  routine  to  examine  all  ca<es  of  slight  trouble 
with  swallowing  in  all  pr()bal>ility  more  lienii:n  new  growths  will  be 
discovered.  Edematous  polyps  and  pedunculateij  liponiata  are  |irol)- 
ably  the  commonest  of  the  benign  growths.     Fibromata  also  occni-. 

These  benign  growths  are  found  chiefly  in  the  u|i|>er  pai!  of  the 
esophagus.  Their  pedicles  allow  tlu'in  to  pia\-  up  and  down  so  that 
they  ajipear  at  one  examinatiini  and  ma\'  disa|ipear  at  the  next  nv 
the>  are  present  when  the  examiner  lii'st  looks  into  the  throat  witli 
the  mirror  and  they  disappear  when  the  |iatient  swallows.  I'edmu'U 
lated  lipomata  ha\'e  a  fashion  of  dropping  forward  into  the  lar\nx 
and  of  causing  cough  and  intermittent   hoarseness. 

Treatment  of  Benign  New  Growths. —  P.enign  new  growths  shouhl 
be  removed  with  api'idpiiate  ura-pinu  or  cutting  forceps.  An  elfort 
should  be  made  to  ohtain  a~.  niucli  of  the  pedicle  and  its  ba.se  as  is 
l>(>ssib!e.  Sometimes  the  maniimlations  ciin  be  carried  out  through 
the  tubular  Sjieculum,  whereas  at  other  times  the  esoiihagoscojH'   is 


248 


oi'Ki;ati\k  sn:(;Ki;v  ok  tiik  xosk,  tiii;oat,  axd  ear. 


necessary.  Tlie  accossihilily  ni'  llic  urowtli  and  the  lolci'ancc  of  llie 
patient  h^ettle  tlic  (|iiestioii  of  llic  use  of  local  or  ,i;ciicral  ancstliesia. 
With  the  cxeeption  of  lipomata  all  supposcilly  heiiign  growths  are 
looked  upon  with  a  certain  amount  of  suspicion.  In  any  given  ease 
time  alone  can  settle   wiicthcr  m   not    this  snspiciim   is  well    founded. 

Malignant  New  Growths  of  the  Esophagus. 

Any  persistent  diftienlty  of  swallowing  in  a  ])atient  of  the  cancer 
age  ought  to  lead  to  a  prompt  examination  of  the  esophagus.  Only  in 
this  way  can  malignant  disease  be  detected  early  and  the  cases  Avhieh 
are  fit  for  operation  sorted  out.    Cancer  of  the  esophagus  often  gives 


FiU.    ISS. 
Section  of  iiovmul  esophagus   (liOW  power). 

but  slight  symptoms  for  a  number  of  years.  It  is  not  uncommon  to 
have  patients  give  a  history  of  tioiiJ)le  with  swallowing  dating  back 
three  or  four  years.  The  horrors  of  cancer  are  nowhere  greater 
than  in  cancer  of  the  esophagus.  If  for  no  other  reason,  therefore, 
these  patients  should  be  given  the  benefit  of  an  eai-ly  examination  and 
of  an  early  diagnosis. 

Malignant  disease  may  start  in  the  epithelium  of  the  esophagus, 
or  in  its  muscular  wall,  or  outside  of  it.  In  late  eases  no  conclusion 
can  be  arrived  at  as  to  origin  of  the  disease. 

Periesophageal  disease,  when  not  far  a<lvaneed,  appears  through 
the  esophagoscope  as  a  hard  nodule  ]iro,jecting  into  the  lumen  of  the 
esophagus  and  ovei'  which  tlie  mucous  membrane  is  normal. 


LAi;vN"i;(istni'\,  HKoNciiiisroi'V,   KsoniAcoscdi'v .  I'/rc. 


1^4!) 


(lOttsti'iii.  (|iicili'il  !•>    .liicUsKii.  (Icsrrilics  tl:c  iiiipciiin >>\'  f.iii'ii- 

of  the  I'soplia.uus  uiiiItT  li\i'  licnU. 

I.  'I'lii'  I'soplKLUcal  wall  -lin\\>  1  liicl;ciicil  wliitisli  |ia1i-lii's.  'I'licsc 
wliitf  itatclu'S  alternate  with  patdir-  of  liri^lil   ivd. 

II.  TIkto  is  a  riiii:  liki'  naridwiim  ol'  the  luincn  of  the  esophaiiiis. 
'I'his  is  called  the  ammlar  l'..i-iii.  At  some  puiul  in  llie  riii.i!,-  tliere  is 
usually  iileeratinii.  i-"rei|iiciil  iy  the  esopha.iius  is  iliiateil  al>nve  the 
eonstfiotiim. 

."!.  Careinoniatous  iuliltratidii  wliieh  is  iii>t  only  annular  in  l'(nin 
Init  l'niinel-shai)e(l. 

4.  Canlirtower  masses  snrronntliim   the   lumen   ol'  tin'   csophaiius 

5.  Papillomatous  veiietalious. 

In  the  author's  oxiterienee  tlie  most  eonmnm  tVu-ms  an'  the  lii>t, 
second  and  the  fourth.  Syphilis  may  stiuudate  any  of  the  live  forms. 
Tile  mieroseoiiie  examination  of  a  specimen  condiined  with  the  thera- 
]tentic  and  the  Wassermaiin  test  will  rule  imt  syjihilis. 

Cancer  of  the  esopha^n-  oei-urs  urteiiest  at  the  upper  or  the  lower 
end.  It  is  not  nncomnKni.  Ikiwcmt.  tn  liml  it  located  ahnut  half  way 
ilowu  the  esojihauus. 

Symptoms  of  Cancer  of  the  Esophagus.  The  chief  sxnipiom  of 
cancer  of  the  esophagus  is  (lifli<-ulty  in  swallowiuii'.  This  symptom  may 
lie  slijjfht  for  years.  Associated  with  the  dilhcnlty  in  swallowiuii",  if 
the  .growth  is  located  in  the  upper  part  i>\'  the  esniihairus,  there  is 
pain  radiatini;-  to  the  ear  of  the  arfected  -idc  (  M'teii  the  cervical  ii-lan<ls 
are  enlargeil.  Tlicy  hecome  infected  cxcn  if  the  I'aiieer  is  situated  at 
the  cardiac  end  of  the  esoi)ha,iiMis.  Later  in  the  disease  when  the  inges- 
tion of  food  is  impeded,  eniaciatidn  si-ls  in. 

Diagnosis  of  Cancer  of  the  Esophagus.  The  old  method  of  making 
a  diagnosis  of  cancer  of  the  es<ipliagu-  was  tn  lahcl  the  dilliculty  in 
swallowing  h\'  some  sueh  name  as  ulnhus  h\slericus,  or  neurasthenia, 
and  to  temporize  until  (ili>l  rncliun  heeaine  marked  and  emaciation 
niiticeahle.  TIh-h  a  IkiU'.;:!'  was  passeil,  an  iili>t  rncl  inn  was  found  ami 
the  liongie  lirnui^lit  up  Mndd.  Tiiday  this  is  antii|nated  surge|-y.  to 
call  it  liy  im  hai'dei-  name.  The  li<Migie  has  cost  many  a  patient  his 
life  not  only  li\'  delaxiug  the  diagnosis  until  ton  late  Imt  also  liy  |h'I-- 
t'orating  the  weakened  wjdis  of  the  cancerous  esophagus. 

Diagnosis  and  Treatment  of  Cancer  of  the  EsophagTis. — Cancer  of 
the  e-iipliai:ns  is  liest  diagunseil  hy  the  esi ipha^osciipe  oi"  l>y  tiu'  open 
"V  liiliular  speculum,  rallialixe  t  re;ii  imiit  j.s  also  hest  carried  out 
llirough  these  instruments.  The  renioval  of  a  specimen  foi'  microscopic 
examination  may  seem  a  lri\ial  affair  in  such  an  ul;1>  disease,  but 
the  snrgi<'al  satisfaction    which   cdines   from   it    is   not    to   he  (h-siiised. 


250 


OPEnATIVR   SrRGlillY   OF   THE   NOSE,   THROAT,   AND   EAR. 


If  the  cancer  is  well  advanced  and  liapjoens  to  be  in  the  njiper  part  of 
the  esophagus  the  tubular  speculum  gives  a  splendid  view  and  enables 
the  surgeon  to  remove  a  generous  specimen  quickly  and  easily.  Good 
biting  forceps  are  necessary  for  this  procedure,   and   care  must  be 


Fig.   189. 
Carcinoma  of  the  esophagus. 


taken  to  pierce  well  into  the  tumor.  (Fig.  189.)  If  the  mucous  mem- 
brane over  the  suspected  area  is  unbroken  it  may  be  questioned  whether 
or  not  it  is  justifiable  to  cut  into  it.    Unless  this  is  done,  however,  the 


I.AItV.VCnSCiPl'V.    HKONl'imSt'OPY,    KSOIM I  .\(  loSCI  )rV.    KTC. 


251 


case  must  be  k'l't  in  ilmilil.  If  llio  cxjiiniiiiitioii  is  cMrriotl  out  uiidcr 
othex"  and  the  jrrowtli  is  situatcil  at  oi-  iicir  tlic  mouth  oi"  the  csoplia^us, 
the  open  s])e('uhnn,  ,u:iv('U  a  t'avoi-alilr  neck,  al'fonls  a  f;:ood  view  and 
enables  the  operator  not  onl\  to  iiiikivc  a  si)ecimen  but  to  i-Kar  away 
a  great  part  of  tlic  fuuijatiii.u-  .urowlli.  In  (•;iiicci-  ln'Iow  the  nioutii  of 
tlie  esophagus,  if  it  is  of  the  caulithiwcr  \y\>r,  cari'Tid   riiretting  will 


^i! 

ir-,,%. 


Fig.    1!)0. 
Soelioii  of  careiiioiiiiitoiis  urea  (low  power).     (Sco  Kij;.   1S9.) 


remove  tlic  i)l)sli'ucliiiL;-  masses  and  ii'ston'  ihr  patient's  alijlity  to 
swallow  soft  food.  'I'lie  aiitlior  lieliexcs  from  lii^  ivsidts  that  this  pro- 
cedure is.jnstiliaiile.  'I'he  eu  ret  tin-  ma>-  lie  repeated  two  or  three  times. 
(Ings.  190  and  ]!)1.)  Tlie  examination  of  a  case  of  cancer  of  the 
esophagus  is  not  ideally  complete  uidess  the  lumen  of  the  cancerous 
stricture  is  ascei-tained  and  tlie  |ire>eiice  of  a  se.-ondai'y  gi'owth  lower 
down  i<  <lef.Tmined.     ( l-'igs.  IDi'  and   i:i:;.)      In  oi-d,.|   to  accomitlisli  this 


OPEKATIVK    SI  r.CKltV    OF   THE    XOSE,    THItOAT,    AXU    EAR. 


Fi-.   liU. 
Section   of   carcinomatous   area    (Iligli   jx'wcr).      (Sre   F^ig.    ]90.) 


Ilg.    l!)i. 

Carcinomatous  stricture  of  tlie   eso|ihagiis 

(Plate  by  Dr.   W.   .T.   DoJil.) 


i.Ain  ^■(;lls^■(ll•^■,  iu;(iNiii(is((ii'\ ,   l■;s(ll'llAl;(lS(•()l•^^,  ktc.  _'.)... 

a  siuallrr  tulii'  slioultl  lu'  iiassct]  tlirini.nli  tlic  lariiiT  csniiliai^uscnpi'  ami 
(•arriod  down  tlirou.iili  tlu>  rest  ol"  llu'  osdiiliauiis.  It  is  iiol  always  Jios- 
sililc  1()  ilo  lliis.  iic\frlliclcss  the  allciiiiit  >liciulcl  Ih'  ma'li'. 


!K 


Cancer  of  the  esopliajjiis.  lU'toiiclied  ti:icin<;  from  X-ray  plate. 
(Laloral  view.)  Tlio  esopliajjiis  is  lilled  with  bismiith  gruel.  At  the  point 
wlipre  tlie  (growth  is  the  esophajjiis  ends  in  an  irrcyfiilar  eone.  Hpjashe.s 
of  bismuth  which  have  passed  througli  the  stricture  are  seen  below. 
i.\nlhor's  case,  i 


W'licii  llic  wall.s  of  till'  csniihaiiu-  air  sni  rniiiidcd  with  liiiiuatinii' 
mas.ses  of  cancerou.s  .UTOwtli  it  is  iianl  In  tril  w  hnv  ilir  Imiini  ,<\'  \\\r 
esopliagus  is  placed.     Ta   siidi   a   ca-r   if  ilir   .-(iiili.i-iis   is   haliooucil 


254  OPERATIVK   SURGERY   OF   THE   NOSE,   THROAT,   AND   EAR. 

with  air  the  displacemont  of  the  cancerous  masses  reveals  the  site 
of  the  esophageal  ojiening'.  If  no  opening  is  found  but  tlie  air  enters 
the  stomacli,  pressure  on  the  abdomen  will  force  the  air  back  and  as 
it  bubbles  upwards  through  the  structure  the  lumen  can  be  located. 
In  extensive  disease  of  the  esophagus  the  esophageal  lumen  can  l^e 
saved  for  a  time  by  intubing  the  carcinomatous  stricture  with  a  small 
elastic  webbing  funnel  after  the  method  of  Mixter. 

It  is  justifiable  to  dilate  a  cancerous  stricture  with  bougies  or 
with  the  mechanical  dilator  only  by  using  these  instruments  through 
the  esophagoscope  and  under  visual  guidance.  Even  with  these  safe- 
guards the  procedure  must  be  employed  with  exti'eme  care. 

What  eveiy  physician  hopes  to  find  in  a  case  of  cancer  is  that  the 
new  growth  is  located  at  the  upper  part  of  the  esophagus,  that  it  is 
not  extensive  and  that  it  is  of  a  low  grade  of  malignancy.  Such  cases 
offer  a  chance  of  cure  if  the  larynx  is  removed  and  the  diseased  por- 
tion of  the  esophagus  resected.  Patients  who  might  liave  been  saved 
by  this  method  have  gone  to  their  graves  without  any  attempt  having 
l)een  made  to  relieve  them.  Such  cases  exist  today,  but  they  will  ncA^er 
be  found  except  by  the  roiitine  use  of  the  esophagoscope.  When  hope- 
less cases  are  encountered,  and  they  are  still  in  the  great  majority,  an 
early  opening  of  the  stomach  will  save  the  patient  from  starving  to 
deatli.  The  author  cannot  understand  the  reluctance  of  some  sni'geons 
to  giving  the  iiatient  the  benefit  of  this  operation. 

Compression  Stenosis  of  the  Esophagus. 

Structures  whicli  border  on  the  esophagus  may  push  ui»on  it  and 
cause  compression.  The  conditions  which  are  commonly  found  to 
do  this  are  glandular  enlargements,  cervical  or  mediastinal  tumors, 
aneurism,  phxral  effusions  and  spinal  deformities. 

The  esophageal  examination  in  these  cases  shows  only  a  nar- 
rowed lumen.  The  general  jjliysical  examination  supplemented  by  an 
X-ray  i)late  are  the  most  efficient  means  of  arriving  at  a  correct  diag- 
nosis of  the  cause  of  the  compression.  In  an  aneurism  the  pulsations 
may  be  seen  through  the  fluoroscope. 

DISEASES  OF  THE  ESOPHAGUS  WHIC'H  DO  NOT  CAl^SE 
STENOSIS. 

Inflammation  and  Ulceration  of  the  Esophagus. 

In  acute  inflammation  of  tlie  eso])hagus  the  usual  signs  shown  by 
an  inflamed  mucous  membrane  are  present.  According  as  the  inflamma- 
tion is  general  or  local  there  is  a  small  or  an  extensive  area  of  redden- 
ing.   Later  the  mucosa  becomes  edematous.    The  vessels  of  the  miicosa 


i.Ainxcosropv.  mtiixciMisi'oi'v,  KsoriiACdscopY,  etc.  _;);> 

:irc  not  as  a  rule  xisililr.  Acute  iiillaiiiiiiatinii  of  the  rsoplia^Mis,  if 
severe,  is  a  coul raimlicat imi  to  the  passaii'e  n\'  tlie  (•soi»liaf;:()SCope. 
Wlu'ii.  luiweviT,  it  is  eauseil  liy  tlii'  preseiiee  of  a  I'lHeij^n  body  tlie  iii- 
tlamiuation  should  bo  disrogarded  ami  the  roroign  body  removed  at 
once.  In  acute  inHaniiuatiou  where  im  cause  is  fouiul.  aTi  uuderlyiim: 
earciuouia  sliould  be  suspected. 

Chronic  Inflammation  of  the  Esophag:us  (Chronic  Esophagitis.)  — 
Chronic  iullainiuati(Ui  nt'  the  esii|iliai;us  may  I'lillow  acute  iullamuuitioii 
but  as  a  rule  it  is  tlu'  ri'^ult  of  tiie  long  continued  irritation  of  ])us 
or  food.  These  are  held  in  the  esopluiii'iis  by  spastic  or  anatomic 
strictures,  or  by  diverticula,  rncoinplicaleil  chiMiiic  catarrhal  inthim- 
inatiou  of  the  esophagus  is  seen  most  often  in  ahoholics.  Here  it  is 
(hie  chiefly  to  the  irritation  of  the  local  iiiitaui.  The  esophagus  is 
usually  a  dirty  gray  or  a  pale  red,  at  times  motth'd  ami  with  the  vessels 
showing.     Tenacious  mucus  covers  it. 

Ulceration  of  the  Esophagus. — Ulceration  of  the  esophagus  occurs 
in   two   forms,   ulcer>   located   above  the  hiatus   and   ulcers   below  it. 


Fig.    J  94. 
Forceps  witli  iiuiioli  tip  for  direct  worlt  upon  the  larynx  or 


esopliagiLS.  Tliis  force])S  is  niadc  in  various  Icngtlis  so  that 
the  punch  can  lie  adjusted  for  any  length  of  esophagoscope  or 
bronchoscope.      (Pfau.) 


1  Icerations  ;ilio\'e  the  hiatus  may  he  dui'  lo  any  of  the  causes  which 
in'oduce  acute  iutlammation  of  the  esophagus,  i.  e.,  to  infection  or 
Irauiiia.  The  ulcers  occurring  in  typhoid  Fcmt  aie  caused  by  throin- 
Imsis  of  the  vessels.  Deep  painless  ulcei-atious  occur  in  syphilis.  The 
same  is  true  of  the;  ulcerations  which  occur  in  tuberculosis.  Tiie  greater 
part  of  the  esophagus  may  be  involved  in  tuberculosis  without  the 
lesion  being  suspected.  Tuberculosis  of  the  esophagus  usually  is  sec- 
ondaiy  to  tuberculosis  of  the  lungs  and  is  due  to  swallowing  s]iutiim.  A 
tuberculous  lu-onchial  gland  may  ulcerate  into  the  esophagus,  though 
this  happens  but  rarely. 

ITcerations  of  the  eso]>liagus  below  the  hiatus  bear  a  strong  re- 
semblance to  pepitio  ulcerations  of  the  stomach.  They  are  often  as- 
signed to  functional  insufficiency  of  the  cardia.  Jackson  believes  that 
the  closui'e  of  the  upper  end  of  the  stomach  is  due  to  a  kinking  of  the 
esophagus  at  the  hiatus  and  that  the  kinking  is  caused  by  the  pressure 


25fi  OPERATIVK  srncEr.Y  of  the  xose.  threat,  axi)  ear. 

of  till'  coiitcnls  oj'  till'  stoiiKich  at  tin.'  I'midus  anil  liy  tlu'  stnu'tiircs 
alioul  till'  hiatus.  The  coulciits  of  the  stoiiiacli,  liowcxcr,  rrcipu'iitly 
iinaili'  till'  lower  part  of  the  esophagus.  I'lcerations  of  the  esophagus 
at  this  jroiiit  have  a  resemblance  to  ulcerations  of  the  duodenum  and 
may  have  the  same  pathology.  Codman  has  made  the  ol)servation  that 
duodenal  ulcerations  are  often  associated  with  tissures  of  tlie  cardia. 
He  made  the  further  observation  at  autopsies  that  fissures  of  the 
cardia  were  not  unconnnon.  The  analogy  is  at  once  suggested  between 
fissure  of  the  cardia  and  fissure  of  the  anus. 

Where  an  ulceration  cannot  be  explained  the  ])resence  of  a  Imried 
foreign  body  should  be  consideieil. 

The  treatment  of  ulceration  of  the  esoijhagus  consists  first  and 
chiefly  in  the  removal  of  the  cause.  After  this  is  accomplished  the 
topical  application  of  nitrate  of  silver,  argyrol,  or  tannin  is  useful. 
The  same  iirocedure  is  advocated  for  the  i)eptic  ulcer.  The  ulcer  is 
cleaned  and  then  dusted  witii  bismuth  powder  or  touched  with  nitrate 


Fig.  Ift.j. 

Mosher's  eurette  for  use  in  examination  by  the  direct  method 
of  the  upper  end  of  the  esophagus  and  the  larynx.  A  simihir 
but  uiuoli  longer  curette  is  made  for  use  with  the  esophagoseope.  In 
dealing  with  inaliguaut  diseases  those  instruments  are  indispensable. 


of  silver.     There  is  no  danger  of  perforation  or  of  heniorrhagi'  if  the 
maiii])iilations  are  carried  out  gently,  and  always  under  clear  vision. 

Neuroses  of  the  Esophagus. 

Sensory  Neuroses  of  the  Esophagus. — The  diagnosis  of  a  sensoiy 
neurosis  of  the  esophagus  should  be  made  with  great  care.  Since  the 
advent  of  the  esophagoscoj)!"  the  number  of  true  cases  of  sensory- 
neuroses  of  the  esophagus  has  been  niaikedly  diminished.  A  routine 
examination  of  such  cases  will  icveal  a  large  number  of  instances  in 
which  the  symptoms  have  a  real  anatomic  or  pathologic  basis.  The 
old  diagnosis  of  globus  hystericus  should  never  pass  unquestioned. 
A  trifling  anatomic  |)eculiarity  like  a  partial  band  at  the  mouth  of  the 
esophagus,  can  readily  cause  these  cases.  The  writei-  feels  that  further 
study  of  the  u]ii)er  end  of  the  esophagus  will  show  that  such  bands 
are  frequent.  Small  ulcerations  from  trauma  could  cause  such  partial 
bands  or  adhesions.     Whether  caused  bv  trauma   or  bv  some  slight 


T.Ai:vN(;(is(()i'V.  ni;(iN(iinsc<ir\ .  ksoi-iiacoscoi'v.  ktc.  _.j< 

irri',i:ul;irity  of  (Icxclnpnifnls  tlic  |.ass;iiiv  nf  a  yod.l  >i/..>il  liminic  uudcr 
the  old  iiiolliod  nl'  licahiiriit  would  liicak  tlir  Imiid  aii<l  clear  up  Uio 
syniittoins,  luit  uol  thr  iliai^unsis.  lii  ohIit  to  luaUc  the  dia.uuosis  as 
ccrtaiu  as  uui.lcru  kudwlcduc  cau  uiakc  il  the  (•s()ip|ia.iii>sc(i])c  luust 
bo  passed  lii'l'oir  lln'  liiiui;ii'. 

Truo  si'iisiirv  inMimso  include  li>  |icii-i  hrsia  of  lln'  I'sojiliauus, 
anostht'sia,  and  paresthesia.  Thi'  patient  gronps  his  symptoms  uuiKt 
the  head  of  a  feeling-  ol"  eontiaction  ol'  the  n])per  part  of  tiie  tiiioat  and 
dillieulty  in  sAvaUowiiiij,  or  as  a  sensation  of  itcliin,i>-,  jtrickinfi'  or  gen- 
eral uneasiness.  Kxeej)!  in  eases  of  true  hysteria  sensory  neurosis  of 
the  esophagus  is  xny  ran'. 

The  aiipiopriatc  trcatnicu)  i>  aloiiL;  m'lii'ial  lucdical  liin's. 

Paralysis  and  Paresis  of  the  Esophagus.— In  eases  wheie  the  iu 
nervation  of  the  esophagus  is  iulcrrcrcd  willi.  all  solid  food  is  swal- 
lowed with  diflieulty.  fluids  are  usually  ^waliowi'd  easily.  .\t  times, 
even  fluids  may  yo  down  wiili  diflieullv  and  ouiy  iu  snudl  ipiantities. 
After  eatin,i>-  there  is  pain  liai-k  of  the  >ternum  and  regururitation  of 
niueus  or  food. 

Contrary    to    eX]ieclatioU    llle    esopliati-oscope.    e\-eu     witllo\lt     ether, 

readily  enters  the  esophaiius  and  i)asses  easily  into  the  stomach.  Tlu' 
case  with  which  it  passes  establishes  the  diagnosis,  because  iu  spastic 
stenosis  spasm  occurs  if  no  anesthetic  is  used,  and  if  there  is  an  anatom- 
ical stricture  this  persists  even  under  ether,  'fhe  iiai-nlysis  may  be 
deinoiist  I  ated  by  Stark's  pill  expeiimeiit.  W'itii  tlie  aid  of  the  esoplia- 
goscope  and  forcejjs  a  pill  or  capsule  is  pL-u-ed  iu  the  esophagus  27  cm. 
from  the  incisor  teeth.  If  tlie  peristalsis  is  normal  the  pill  will  l)e  car- 
ried into  the  stomach;  if  the  pill  remains  wheiv  it  is  placed  a  paralysis 
or  an  abnoiinal  feebleness  of  the  esophageal  wall  exists. 

Tile  chief  causes  of  paralytic  couditious  of  the  esophagus  ai'e  cen- 
tral uer\e  lesi(Uis,  till'  most  commou  beiug  bniliar  jiaralysis.  and  the 
neuritis  which  follows  alcohol,  diphtheiia,  and   lead  poisoning. 

When  a  paral\tic  coudilniU  of  the  esophagus  is  suspected  a  iieuro- 
loi;ic  examination  is  called  I'oi-,  and  if  sucii  a  condition  is  proxcd  the 
treatment,  of  C(uii'se,  is  almig  general  lines. 

Congenital  Anomalies  of  the  Esophagus. 

Congenital  anomalies  of  the  esophagus  occur  occasionally.  The 
esophagus  ma\'  be  bilid  uv  douiile  or  it  may  end  iu  a  blind  jtoneh. 
Children  iia\-ing  these  deformities  sc'Idom  lixc  foi-  any  lcnL;th  of  time. 
Rarely,  a  fistula  Joins  the  trachea  and  the  esophagus.  Cases  of  this 
kind   ha\'i'  been   reporteil   and   the  patients  have  survived.     This  was 


258  Oi'KIlATIVE   srP.tlERY   OF   THE   NOSE,   THROAT,   AND   EAll. 

possible  for  tlic  reason  that  a  valve-like  fold  of  imicDiis  iiu'iiiliraiic 
prevented  food  from  getting  into  the  trachea. 

Congenital  Stricture  of  the  Esophagus. — A  little  girl  about  a  year 
old  \vas  referred  tn  the  autluu'  with  the  history  that  she  had  swallowed 
a  "pacifier,"  and  had  liad  almost  complete  obstnictidii  to  swallowing 
since  the  accident.  The  baby  was  very  jiooi'ly  nonrished  and  it  Avas 
found  on  questioning  the  parents  that  from  liirth  she  had  contiiuially 
thrown  up  her  food.  It  was  supposed  naturally  that  the  milk  was  not 
of  the  proper  kind.  Both  the  milk  and  the  physician  were  I'epeatedly 
changed.  The  baby  just  managed  to  survive  up  to  the  time  when  it 
made  a  meal  of  the  "pacifier."  It  speedily  vomited  the  rubber  nipple 
which  was  on  the  end  of  the  "pacifier."  Notwithstanding  this  it  could 
not  retain  any  milk.  A  local  specialist  passed  an  esophagoscope  and 
thi'ough  this  introduced  a  liougie,  but  could  not  make  it  enter  the 
stomach.  At  this  point  in  the  case  the  author  saw  the  child.  The 
X-ray  showed  a  small  round  body  apparently  in  the  esophagus  and  at 
the  level  of  the  bifurcation  of  the  trachea.  This  Avas  supposed  to  be 
a  bit  of  bone  from  the  "pacifier."  On  examination  under  ether  this 
bit  of  bone  was  neither  seen  nor  felt,  but  instead  a  stricture  Avas  found. 
This  was  at  the  level  of  the  bifurcation  of  the  trachea  and  readily  ad- 
mitted a  No.  16  F.  bougie  and  was  easily  dilated  up  to  No.  20  F.  Sub- 
sequent dilatations  carried  the  lumen  of  the  stricture  to  '26  F.  After 
a  few  days  the  baby  began  to  retain  milk.  A  second  plate  showed  that 
the  bit  of  bone  which  gaA^e  the  round  shadow  in  the  first  plate  had 
disappeared  after  the  examination.  The  stools  Avere  searched,  but  it 
Avas  ncA'er  found. 

The  folloAving  seems  to  be  a  reasonable  explanation  of  this  case. 
The  child  had  a  congenital  stricture  and  she  forced  its  discoA^ery  by 
SAvallowing  the  rubber  nipple  fi'om  the  "pacifier"  and  perhaps  a  bit 
of  bone  from  the  handle.  The  first  examination  pushed  the  piece  of 
bone  through  the  stricture  and  the  second  pushed  it  into  the  stomach. 
The  second  examination  determined  the  presence  of  the  stricture  and 
led  to  its  dilatation. 

Diverticulum. — A  diverticulum  is  a  pouch-like  off-shoot  from  the 
esophagus.  The  so-called  traction  diA'erticulum  is  the  easiest  of  ex- 
planation. It  is  caused  by  the  contraction  of  sear  tissue,  arising  from 
a  suppurating  gland  in  process  of  healing.  This  ucav  tissue  exerts  a 
pull  upon  a  circumscribed  part  of  the  esophageal  Avail  and  makes  a 
pouch.  In  certain  animals  pouches  and  dilatations  of  the  esophagus 
are  nonnal;  for  instance,  the  crop  and  the  dilatation  of  the  loAver  por- 
tion of  the  esophagus  in  birds.  Something  of  this  tendency  to  A^ariation 
in  form  maA'  be  retained  in  man.     In  one  of  the  author's  cases  the 


l.\i;yxi;osc(ii'v.  I!^,()^•('lH)st'lll'^ .  KsdniAciiscoi'V,  kit.  25?) 

iiioiitli  i>\'  till-  csiiplmyus  \v;is  \fry  wiilc  ;is  if  llif  |ili;iiyii\  rxtciiilol 
1h>1o\v  the  cricoid  cartilauv  and  had  tlnTr  :ii  iriii|itic|  in  mnki'  a  doiililc 
(■so])lian-us,  tlu'  iinsucccssfid  atl('iii]it  Kfiuu  ilir  iniiicli. 

nivcrticula  arc  ciicouiitci-cd  iiiost  dl'tfii  in  tin'  ii|i|iri-  part  nf  tlio 
osoi>iiag'ns  near  the  cricoid  cartilaiic  In  cvciy  csopiiaui'al  cxaniinalion 
the  i>ossil)ility  of  Hndinn'  a  pouch  must  he  hoi-ne  in  mind  and  its  exist- 
ence ruled  out. 

S/niipidiiis. — Tile  symptoms  ol'  a  small  pouch  arc  not  iiiarki'il 
(■iioui;li  to  make  tlie  examiner  do  moie  llian  sus])ect  it>  prc-cncr.  The 
cliief  sjnnptoms  are  slight  dilliculty  in  swallowing  and  soon  after  eat- 
inj;  the  regurgitation  of  a  small  amount  of  undigested  or  putrid  food. 
Where  a  poucli  has  existed  a  long  time  and  has  dissected  its  way 
downward  between  tlie  nmsi-h'>  of  tlic  neck  and  pci'haps  into  the  rlicst 
tlie  symptoms,  although  of  tiie  same  general  ciiaractrr,  are  much  more 
marked.  It  is  imjjossihle  from  the  .symjitonis  to  din'crenliate  such  a 
case  from  one  of  phrenospasm  and  dilatation  of  tiie  est)phagns. 

Diafinosis. — If  the  ))resence  of  a  ])ouch  is  sus|)ected  the  ]iliysician 
may  give  the  patient  lii>nMitii  and  then  lake  an  X  ray;  oi'  he  may 
give  the  patient  bird  shot  to  swallow  and  then  take  the  plate;  or  he 
may  jiass  a  bougie.  The  bougie  on  its  iirsi  introduction  meets  with 
an  obstruction  high  n)i  in  the  csopliagns  and  then  if  it  is  withdrawn 
and  reintroduced  it  (■ntcr>  llu'  luini'ii  of  the  esopliagns  and  cmitinues 
on  into  the  stomach.  .\o  one  of  ihcsc  three  methods  is  as  satisfactory 
as  the  diagnosis  of  a  diverticnlnm  by  sight.  An  .X-i'ay  ])late  of  an 
esophagus  tilled  with  l)ismiitli  often  gives  the  impression  of  a  pouch 
where  muie  exists.  This  is  dne  to  spasm  of  the  esophageal  wall. 
llriinings  lias  a  1)eaked  tubular  speciiliim  the  lower  half  of  which 
has  a  slit  in  the  side  In  using  tliis  the  atti'mjit  is  made  to  mm'age  the 
beak  of  till'  spcciilimi  in  the  o|ieiiini;'  of  the  esopliaL;u-  and  after  this 
has  been  locate(l.  tu  liiid  tlir  dpciiiim  ul'  thr  ponch  hy  examining  the 
esophageal  wall  tiii'oiigli  the  .-lit  in  the  >idr  of  the  instrument. 

In  the  search  for  diverticula  the  hailodning  attachment  I'nr  the  oval 
esophagoscope  is  of  the  greatest  sei\  ice.  There  is  usiiallx-  no  trouble 
in  lindim:"  the  pinn-li.  as  the  esophagoscope  goes  into  it  most  ivadily. 
••nee  in  the  pnueli,  the  exaiiiiiK/r  sees  iio  esopliageal  imiien  ahead. 
instead  theri'  is  an  iinlirokeii  wall.  ( tii  attempting  to  readjust  the 
Itiiig  axis  of  tlie  tiilie  to  eonl'orm  to  tlie  lung  axis  of  the  esophagus 
-till  11(1  limieii  appear>.     If  imw    the  window    plug  is  inserted  and  the 

poucli  disteiidi'd  with  air  the  Faei    that    ti iid   nf  the  esophagoscoi)e 

is  in  a  cIoscmI  cavit>'  liecdines  clear.  .Xni  unly  tin,-,  Imt  the  size  of  the 
pimch  can  lie  made  out  and  the  Cdiiditiim  of  its  walls.  The  bottom  of  the 
|)ouch  is  found  in  many  cases  to  he  thickened  and  inflamed  from  the 


2G0  OPEKATIVE    STRCEKY    OF   THE    NOSE,    THItOAT,    AND    EAT.. 

rotontioii  aiul  niaccrjitiun  of  food.  When  the  |ii)iicli  has  lu^i  u  outliiKMl 
in  this  way  if  1  lie  csoplia^'oscopc  is  shiwiy  w  i1  h<lia\vii,  and  all  t  he  w  hih' 
air  is  forceiJ  inlo  tlic  ]>oin'li,  at  the  nionirnt  when  tlic  end  n\'  ihc  csopli- 
ag'oscope  leax'cs  the  mouth  of  tlic  pimcli  and  is  ojipdsitc  the  (ipfuinsi,' 
of  th<>  osoplia.ii'us  t\\()  (ipciiing's  will  he  socn  throiinii  tlic  luhc  Tlie 
new  o]ieniiiy  will  proNC  on  oxaniination  td  lie  the  lost  opening;-  of  the 
esoiihagus.  This  is  l)y  far  tin-  hcst  nictluid  of  dctcnnininii'  the  in'cscncc- 
of  a  divertieiihim. 

Treatment  of  EsophnjicaJ  Direrticuhi. — If  the  ])ou('h  is  large 
onougli  and  not  too  large,  that  is,  if  it  does  not  extend  into  the  chest, 
it  may  be  dissected  out.  This  is  the  treatment  advocated  at  the  Mayo 
Hospital.  Small  and  medium  sized  pouclies  may  be  cured  symptomati- 
cally  by  dilating  the  esophagus  at  the  point  Avliere  the  pouch  leaves 
it.  This  is  done  by  first  finding  the  pouch  and  cleaning  it  of  food 
and  then  stretching  the  esophagus  with  the  mechanical  dilator.  After 
this  a  thread  is  passed  through  the  esophagus  into  the  stomach  and 
allowed  to  engage  in  the  upper  part  of  the  intestinal  tract.  As  soon 
after  the  ether  examination  as  the  thread  has  become  well  anchored, 
the  metal  staff  of  Mixter  with  its  perforated  olive  is  carried  down 
on  the  thread  and  olives  of  increasing  size  are  forced  down  on  the 
staff.  After  a  week  or  two  the  metal  staff  will  find  the  esophageal 
opening  unguided  by  the  thread  and  the  thread  may  be  allowed  to 
pass  on.  The  physician  soon  finds  that  he  can  pass  elastic  bougies 
also  of  increasing  size,  through  the  esophagus.  Lastly  the  patient  is 
taught  to  ])ass  a  bougie  of  reasonable  size  for  himself.  This  has  to  be 
continued  for  an  indefinite  time.  Mixter,  who  has  had  much  experience 
both  with  excision  of  the  pouch  and  with  the  symptomatic  cure  by 
dilatation,  favors  for  the  general  run  of  cases  the  treatment  hy  dilata- 
tion. 

Some  day  it  may  seem  feasible  to  cut  the  common  wall  between  a 
small  pouch  and  the  esoiihagus.  When  this  procedure  is  attempted 
it  will  be  carried  out  if  it  is  to  be  performed  in  a  surgical  fashion, 
through  the  esophagoscope.  The  writer  tried  this  in  a  rather  hesitat- 
ing manner  on  one  case,  and  is  waiting  for  an  appropriate  ease  to  try  it 
again.    The  results  were  mediocre,  i.  e.,  no  better  than  dilatation. 

Dilatation  of  the  Esophagus. 

In  dilatation  of  the  esophagus  the  whole  structure  becomes  en- 
lai-ged  and  acts  as  a  sac  instead  of  a  tube.  The  most  common  form 
is  a  spindle-shaped  esophagus.  From  certain  obsei-A-ations  the  au- 
thor is  of  the  opinion   that  a   dilatation  of  moderate  degree   of  the 


I.Al;v^■c;(lSl•(l|•^ .  iiiioNciKiscdrw  i:siii'ii.\iii)stni>\ ,   i;ic.  L'lil 

IdWrr  tliinl  ol'  till'  csdiilia.nus  is  <'<)iiimiiii.  if  iml  ikuihiiI.  It  i>  n  rt.iinly 
not  umisual  in  ilissi'ftiii.n"  I'odiii  Ittulics. 

Tilt"  lower  part  of  tiit-  i'so|iliay:iis  is  tin.'  part  most  ol'tcii  I'lilarniMl. 
Tlif  ililatatioii  is  dm'  citlicr  to  an  anatomic  siriftnrc  or  to  a  spastic 
closure  at  some  point.  Tiic  forms  of  striclnie  have  licm  discnsscd. 
Spastic  closure,  as  has  been  said,  is  due  a>  a  rule  in  -pasm  of  (lie 
hiatus  of  tlio  esophagus  or  to  spasm  of  Ilie  caidia.  l>ilalali(Oi  of  the 
eso]>lia.a:iis  is  spoken  of  at  this  i)oint  under  a  separate  lieadiii.u,  and 
after  diverticula  of  the  eso|tlia.nus  ha\e  lieeii  discussed,  hecause  the 
two  conditions  have  to  he  dilTerentiatcd. 

The  diaiiuosis  is  made  hy  examining;  the  liiiuen  di'  liie  esophaiius 
through  the  eso|>ha,uoseo)H'.  In  the  norma!  esophaiiUs  the  wells  Iiujj: 
the  exaniiniiiii'  tube  and  are  seen  to  he  continuous  with  the  end  of  tiie 
tuhe  foi'  some  distance  aliead.  If  tlie  esophaitus  is  dilated  the  end  of 
the  esophajioscojje  linrls  itself  in  a  laiiic,  dark  cavt'iu,  tlii'  walls  of 
which  become  clear  only  as  llie  tube  is  umvecl  slroimly  from  side  to 
side.  The  ojieniui;'  of  tlie  esophanns  lielow  the  dilatntinu  may  not  be 
in  the  center  of  the  dilated  portion,  but  eccenliii-.  Not  uidy  this, 
but  the  dilated  jiortion  may  sa,y  below  the  level  of  the  esophancal 
opeuinii'  and  make  a  deep  moat  about  it.  Most  often  the  sa,a:.i!;in<i:  of 
the  dilated  jiart  of  the  esophajius  below  the  opening'  of  the  esopha.uus 
occurs  to  the  rii-lit  of  the  esoi)hai;eaI  opeiiinu-.  It  is  into  tliis  sau'iiiui,^ 
part  of  the  esoiilia.itus  that  tlie  poim  of  the  exaniininii,-  bouiiie  invariably 
finds  its  way,  and  it  is  a1  this  pdiut  that  perforation  of  the  esophaiius 
from  rouyh  mauipiilatinu  witli  bdunies  nrcurs  luosi   frei|U('iitly.     When 

this  pouch-like  collar  in'ciir^  at  tln'  lower  i  ud  n['  ll sopliauus  the  use 

of  a  metal  staff  with  an  dlixi'  (Ui  the  r]\,\  enable-.  tlh>  cxaiuiner  to 
swin.a:  the  ]ioint  of  the  olive  to  the  hit  and  to  lisli  siic<'essfully  for  the 
ojienins"  of  the  eso))lia,uus.  I'>allnnuiim  the  isnphayus  smooths  the  folds 
and  makes  the  lumen  stand  (Mil  deailv. 

The  treatment  of  dilatatidii  nf  tl suphaun-  i>  to  treat  the  con- 

<1ition  which  causes  it.     This  ha-  already   been  i;i\-eu. 

Foreign  Bodies  in  the  Esophagus. 

Jackson  bejiins  his  diapler  on  j'oreiiiii  bodies  in  the  csopha,i::us 
with  the  followiiiii'  sentence-;  "(  (lusiderim;-  the  iuillianl  achiexfinents 
of  esojihas'oscopy  in  the  renii>\al  nf  l'cireii:n  Imdies  t'lipiii  the  esophaiius. 
it  is  time  to  proiioiiner  the  |n-e\alent  use  nl'  tiie  sdund,  the  x^erlcbrated 
forceps,  the  coin  calclier,  the  bristle  ami  spuniic  probaniis  obsolete, 
dan.Jrerous,  unsuru-ji-al  and  uttei-ly  unjust  iliaMe.  There  are  numerous 
cases  on  reemd  nf  fatal  re-nlts  from  tlii'ii'  u>e,  and  thei-e  aic  many 
time^  as  many  cases  that   lia\e  ni'\ei-  been  i-ep(iited. "     This  laiiiiua.ire 


2G2  OPEKATIVE   SURGERY   OF   THE   NOSE,   TIUtOAT,   AND   EAR. 

is  none  too  strong,  especially  when  applied  to  the  use  of  these  instni- 
nients  in  cases  of  rough  or  sharp  foreign  bodies. 

Foreign  bodies  lodged  in  the  esophagus  fall  naturally  into  two 
groujos,  smooth  foreign  bodies  and  rough  or  pointed  ones.  In  tlie  tirst 
class  are  penny  whistles,  buttons  and  coins.  Prominent  in  the  second 
are  pins,  needles  and  safety  pins,  fish  bones,  chicken  bones,  meat 
bones  and,  lastly,  partial  or  complete  tooth  plates.  Coins  often  lodge 
for  a  while  and  then  go  down,  although  there  are  many  cases  in  which 
coins  have  failed  to  jjass  into  the  stomach  but  have  remained  in  one 
position  and  ulcerated  into  the  aorta  or  trachea.  Pointed  and  sharp 
objects  as  a  rule  lodge  and  finally  perforate  and  generally  prove  fatal. 

Ordinarily  patients  come  to  the  physician  with  the  history  that 
they  have  swallowed  a  foreign  body.  This  is  not  always  the  case, 
however,  because  it  sometimes  happens  that  they  come  simply  for 
difficulty  in  swallowing.  In  infants  regurgitation  of  food  may  be  the 
only  symptom.  Older  children  may  swallow  liquids  but  not  solid  food 
and  there  is  a  persistent  cough.  Patients  often  think  that  a  sharp 
foreign  body  is  still  in  the  esophagus  when  in  reality  it  has  passed 
downward.  The  scratch  or  abrasion  caused  by  it,  and  this  is  especially 
true  of  fish  bones,  for  some  days  makes  the  patient  feel  that  something 
is  wrong  and  he  interprets  his  abnormal  sensations  as  the  continued 
presence  of  the  foreign  body.  Witliout  an  esophageal  examination  it 
is  very  hard  to  disabuse  the  patient  of  this  idea.  Patients  seldom 
localize  the  position  of  the  foreign  body  accurately. 

Places  Where  the  Foreign  Bodies  Lodge. — Foreign  bodies  in  the 
eso])hagus  lodge  most  often  l^ack  of  the  cricoid  cartilage.  If  they  are 
dislodged  from  here  they  stop  again  at  tiie  lewl  of  the  inner  end  of  the 
clavicles.  Anatomic  narrowing  is  said  to  be  responsible  for  this.  Once 
beyond  the  clavicles  smooth  foreign  bodies  almost  always  find  their 
way  into  the  stomach  and  any  smooth  foreign  body  which  gains  the 
stomach  as  a  rule  can  pass  the  pylorus.  It  is  astonishing  Iioav  large  an 
object  can  do  this.  The  author  has  known  a  flat,  mother-of-pearl 
button  one  inch  in  diameter  to  pass  from  the  stomach  of  a  one-year-old 
child  into  the  intestinal  tract  and  to  l)e  recovered  in  the  stools  in 
twenty-four  hours. 

Procedure  to  be  Followed  in  Cases  of  Foreign  Bodies. — Tlie  his- 
tory of  the  case  is  taken  and  the  parents  or  the  friends  of  the  patient 
are  instructed  to  bring  a  du]ilicate  of  tl:e  foreign  body  if  it  happens 
to  be  a  nail,  a  pin,  or  a  button.  The  physician  can  probably  furnish 
a  duplicate  if  the  foreign  body  is  a  coin.  Unless  the  case  happens  to 
be  desperate  from  pressure  upon  the  trachea  an  X-ray  plate  is  taken. 


LAinxcost'opv,  nnoxriroscoPY,  ksopiiaooscopy,  etc.  -('>'■'> 

This  (letiTiiiiiu's  tlio  piisitioii  of  tlic  forciiiii  body  ami  in  casL-  its  iialuiv 
is  not  known  often  disc-losi'S  it.  Xoxt,  apiHoiiriatc  instrnnu'nts  for  the 
extraction  of  tlie  foivi.nn  l)oily  are  selocti'il  or  nlitaiind.  Sin-ci'ss  in  tho 
ivnioval  of  foroiyn  liodics  loilned  either  in  llie  liailna  or  in  the  csopli- 
a.uns  depends  nimn  two  things,  tiie  nieclianieal  sense  ami  <le\terity 
of  the  oju'rator.  and  suitaltle  instrnnients.  In  the  matter  u\'  instrn- 
ments  it  is  vitally  important  to  select  .uraspin.n'  forceps  with  l)la<les 
adapted  to  seizini;'  the  particular  foreign  body  in  hand.  (Fig.  191!.) 
On  the  duplicate  foreign  body  the  forceps  chosen  can  be  tested.  If  the 
dnj^licate  foreign  body  is  plai-ed  in  a  piece  of  rnl»ber  tubing  the  manipu- 
lations necessary  Inr  it.-  extraction  can  lie  jn-aeticed.  Such  jiractice 
leads  to  sureness  and  eonlideuee  and  these  in  turn  lead  to  success. 

Before  using  the  tubular  speculum  or  the  esoi)hagoscope  a  system- 
atic examination  is  made  with  head-light  and  mirnn-  of  the  jiatieut's 
mouth  and  pliarynx.    The  crypts  of  the  tonsils,  the  supratonsillar  fossa 


Fig.  196. 
.lackson  's  foreign  liody  forceps. 


and  tlie  \allecnla'  at  the  iiase  of  tlie  tongue  and  the  pyi-ifoi-m  >inuses 
are  examined  in  turn.  Imiiacted  ccmcretions  in  tlie  supratonsiUar  fossa 
often  give  the  sensation  of  a  foreign  body.  If  a  good  view  cannot  be 
oljtaineil  after  cocaini/.ati(ni  and  if  the  foreign  body  liaiipeiis  to  lie 
small  like  a  lish  bone  or  a  iiin.  the  base  of  the  tongue  and  the  jiyriform 
sinuses  are  explored  with  the  tip  of  the  finger.  Should  the  foreign  body 
happen  to  be  a  coin  this  maTii]inlatioii  is  not  einiiloved  for  fear  that 
the  gagging  caused  by  it  might  di-lodge  the  coin  tVinn  the  grasp  of 
the  inonfli  of  the  esophagus  and  stai't  it  downward,  for  tlie  same 
reason  .-(nin<l>  and  liougies  are  not  passed. 

Choice  of  the  Anesthetic.-jAfter  the  cxainination  of  the  mouth 
and  pharynx  has  proved  negative  the  operatnr  decides  whether  tlie 
examinaticm  with  tlic  tnbuLir  siiecnlum  is  to  be  caiiicd  cmt  nihlci- 
local  or  general  anesthesia,  ^fany  successful  extractions  of  loiei,:;ii 
bodies,  notably  in  the  Gennan  clinics,  have  been  performed  under 
local  anesthesia.  Kven  partial  tooth  plates  have  been  so  removed. 
Some   allowance   must    be   maile    for   the   temperaineni    of   the    patient 


ICA 


OPERATIVE    sriKiEin    OK    THE    NOSE,    THKOAT,    AND    KAU. 


ami  also  for  the  tciiiperainnit  of  tlic  operator.  Tlie  aiitlior  lias  re- 
])eato(]ly  expressed  his  indixidiial  preference  for  general  anesthesia. 
If  the  operator  pi-efers  the  sitting  position  ami  cocain  aiic-tliesia,  well 
and  good,  provided  that  the  resnlts  ai'e  good;  if,  (in  the  other  hand, 
he  should  prefer  general  anesthesia  and  the  pnnic  ]iosition  of  the 
patient  lu^  should  not  be  rnled  ont  of  court. 

Coins  and  Buttons  in  the  Esophaorus. — Coins  and  buttons  and  for- 


Fig.  197. 

Penny  lodjieil  in  tlie  uiiiier  part  of  the  esophagus  of  a  child. 
The  penny  is  well  aljovc  the  level  of  the  clavicles,  that  is,  it  is  just 
))elo\v  the  mouth  of  the  esophagus  and  oppiosite  the  cricoid  cartilage. 
(X-ray  tracing  retouched  and  reduced.  Drawing  made  by  the  author. 
From  the  throat  clinic  of  the  Massachusetts  General  Hospital.) 


eign  bodies  of  similar  form  usually  lodge  behind  the  cricoid  cartilage. 
These  cases  usually  occur  in  cliihlren.  The  first  thing  which  the  physi- 
cian should  remember  when  he  encounters  such  a  ])atient  is  to  keep 
his  finger  out  of  the  child 's  mouth.  (  Fig.  1!I7.)  If  the  X-ray  ]date  shows 
that  the  coin  is  sticking  behind  the  cricoid  cartilage  and  the  pjatient  is 
an  infant  or  a  young  child,  it  is  wrapped  in  a  blanket,  placed  on  its 
back  on  the  examining  table  and  the  head  is  brought  over  the  end  of 


i,.vi;vx(i(isf<irY.  idioxciiosioi'v.  i;s(iPii.u;()scorv,  ktc.  2Gn 

tile  tal)li'  :uul  lu'Id  liy  jui  assistant.  If  tin*  child  is  ton  larnc  tn  lie  (.'((n- 
tidlk'il,  otlitT  is  nivcii.  Till'  operator  lias  a  choico  of  insti-iiiiiciits  for 
liriiiiiiiiU-  tlio  coin  into  view,  tlic  closed  tuhnlar  spcculnni  of  Jackson 
nr  Ih-iiniiiiis  and  the  adjnslahle  specidnni  of  the  anthm-.     If  tln'  ad.jnst- 

aMc    Spccullllll    is    selected     the     piiint     nl'    tlle    -peeullllll     is     pa>Sed     lllhlel' 

its  own  ilhuninatiiin  or  undtT  the  illuniinalioii  of  the  head  iiiirnii'  - 
and  no  illumination  cfjuals  that  of  the  head  mirror  for  short  distances 
■ — until  tlie  i)oint  of  the  s|>ecnluin  is  en,i;'a,i::e(l  hehind  the  i-inij-  of  tlie 
cricoid  oartilasi;!'.  When  the  cricoid  cartilage  is  lield  forwaiil  it  is 
l"ossil)le  to  see  down  the  hiinen  of  tlie  esopiianus  almost  to  thi'  level  of 
the  clavicles.  Coins  and  Inittons  lie  Hat  a.iiainst  the  vertelual  euhiniii, 
so  that  the  operator  sees  only  the  upjier  eili^e  of  the  lini  dI'  the  coin. 
This  appears  as  a  dark,  transverse  line.  The  ed.u'e  of  the  cnin  heiny-  in 
view  it  is  a  simple  procedure  to  jiass  a  jiair  of  aiimilar  fmceps  and 
rt'move  it.  The  tuhidar  s])ecnlnm  can  lie  eiiiploNed  in  the  >aine  wa>.  It 
does  not,  howe\'er,  ,ui\'e  siu-h  a  wide  lield  I'm-  opeiatiim  as  1lie  adjust- 
able speculum.  If  the  coin  is  hehiw  the  reach  of  the  speculiiiu  an 
esopliaii;oscope  of  a|iprcipriate  size  is  iiitrn<luced  into  the  esopliaj>'us 
and   carried  down   care|'nll\    uiilil    the   foreii:n    limly   cdiiies   into   vi(>w. 

As    lar.U'C    a    lllhe    simuld    he    used    a-    po-siMe,    liecailse    it     is    liUinilialillii' 

\ ct  true,  that  a  small  bromdioscope  may  pass  a  coin  witluint  tlu'  exam- 
iner seeina,'  it,  or  detectiuij'  it  by  striking-  it  with  the  cimI  of  the  tube. 
A  manipulation  which  will  occasionally  biiiiii  the  cuin  to  \  iew  is  to 
elevate  the  handle  of  the  tube  stronnly  and  to  press  the  point  a.i!:ainst 
the  vertebral  column.  This  saved  the  author  on  one  occasion  from  the 
embarrassment  of  defeat  in  the  case  of  the  child  of  a  ]»liysici,in.  When 
a  button  or  a  coin  is  lodi;ed  in  the  thoracic  poiliou  of  tin'  esopiia.srus 
as  the  examinin.ii'  tube  approaches  it  t  he  lumen  of  the  esophai; us  chanji'es 
from  the  customary  rosette  to  a  transverse  slit.  In  this  dark  trans- 
verse slit  tlic  foreii^u  body  is  lodncd  an<l  i^  lioldiim'  the  esophaii'eal 
walls  apart.  The  lirst  urasp  of  the  forceps  upon  the  coin  should  be 
a  sin'e  one,  because  if  the  .'oin  is  nihlijed  and  not  lirnily  seized,  the 
operator  may  have  the  umrt  ilicat  ion  of  seciuL;-  it  disappear  down  the 
esojtha.nns.  If  he  catches  si.nht  of  it  auain  he  is  rortunati';  .iieiierall>' 
it  has  g'one  into  the  stomach.  If  before  or  during  the  examination 
the  patient  vomits,  examine  the  voinitns.  The  fori'iiiii  body  may  be 
found  ill  this.     (V]u:  lOS.) 

The  Bristle  Probang".  The  use  of  the  biistle  probant;-  is  allowalile 
only  in  case  a  bolus  of  meat  or  a  sinootii  foreign  body  like  a  coin  or 
a  button  is  lo'l.iicd  In-hind  tin-  ciicoiil  carlila'_;e.  Its  use  in  siicli  cases 
is  often  successful  and  is  without  daiincr.  A  more  surgical  procedure, 
howe\-er,  is  tn  use  the  speculuin.  When  munii  foreiiz'ii  bodies  lilce  lisli 
in-  chicken    bone-   oi-   pin-   aii-   tn    he   .|c;ilt    with    the    n-e   of  tile   lii'istle 


2(i(; 


>i'i'',i;A'rivK  srncKr.v  oi'-  tiik  xosk,  TiiitoAT,  Axn  eai;. 


])r()l)iiHi;  is  riiiiti;iiii(lieato(l.  lu  the  rare  cases  in  wliicli  the  use  of  tlu' 
tubular  s|ic(Miluin  oi'  tlie  esophas'osrope  fails  to  disclose^  tlie  foreiiiii 
Ijod)-  the  bristle  i)robang  comes  a,i;aiu  lo  its  own.  If  a  min  di'  ;i  liutlon 
caunot  be  found  ajid  extracted  it  is  a  y-ood  ]iracticc,  at  least  ti-oiu  the 
standpoint  of  the  iiatient,  to  push  it  down.  ( )pcuiu,L;'  the  sidf  of  the 
neck  for  the  removal  of  a  smodth  fdi'ciiiii  body  of  this  nature  is  obsolete 
surgery. 

Pins  in  the  Esophagus. —  When  a  jiin  is  lodged  in  tlu'  csojihagus, 
esp('i'iall>'   when   its  point    is  turned  downward,  it  does   not  as  a  rule 


Fig.  198. 

Penny  whistle  in  the  uj)por  pait  of  the  esopliagus  of  a  seven  yeai'  okl 
chihl.  The  whistle  lodged  just  below  the  mouth  of  the  esophagus  and  behind 
the  crifoid  cartilage.  This  is  the  favorite  place  for  foreign  bodies  to  halt. 
The  wliistle  was  removed  under  ether  with  the  author's  open  speculum  and 
angular  forceps.  Such  eases  are  best  managed  with  the  tubular  or  the 
open  speculum.  (Author's  case.  X-ray  tracing  retouched  and  reduced. 
Massachusetts   Charitalde  Eye  and  Ear  Infirmary.) 

give  much  trouble  in  the  extraction.  When,  on  the  other  hand,  the 
l)oint  of  the  ]iin  is  ujtpermost  and  embedded,  its  removal  may  be  very 
difficult.  Casselberry's  pin  cutter  which  divides  the  pin  and  holds  the 
fragments  is  practically  indispensable  for  the  proper  management  of 
such  eases. 


LAUVXCOSC'dl'V,    liKdN'Clinstnin.    i:sol'll.\(i()S((lPY,    K'l'l". 


L'(i7 


Safety  Pins  in  the  Esophagus.— ( Ki.n-.  1!>!*.)  An  open  siitVly  pin, 
jioiiit  lip.  is  one  (if  tile  liiiriji'st  (if  rorciyn  Itoilics  to  rcniow  frdni  tlic 
t'sopliiiiius.  Tlio  Jiiin  of  till"  opi-ralor  is  to  close  the  pin.  Tiiis  ac-coni- 
piisiuHJ,  the  oxtrju'tion  is  cjisy.  Coolidi'V,  sonio  (•i,ii:ht  yoars  a,i;(),  was 
tlio  Hrst  to  romovo  a  satVty  pin  runii  tiu'  csopiia.uns.  lie  used  a  satVty 
pin  elosor  doviscd  liy  tin-  aiilliur.  Since  the  time  of  this  case  other 
methods  ha\  e  lieeii  devised  lor  sucressfully  ch)sinfj:  a  safety  pin.  Within 
the  hist  year  ,laci<s()n  lias  introduced  a  darina;  and  simple  method  of 
ch)sini;- and  extractin.u;  a  safety  pin.  ( Fi.ijs.  "JOO  and  liOl.)  Thron.uli  tlie 
esophauoscope  with  forcejJS  tipped  witii  two  shMuler  inlei-h)cl<in,n-  black's 
he  grasps  the  rinj"-  of  the  ])in.     When  the  hhuh's  of  the  force] is  are 


Fig.  niii. 

Safety    pin    in    tlie    esoplia;;iis.     Child    two    yciirs    old.     .Xutlior's    case. 
Kxtrac'tion   by  means  of   the  esoiihagosco])e   failed   and    the   i)in    wa.s   piiahed 
into   the   stomach   and    removed    by   incision.     The   child   died   of   pneumonia. 
(Plate    by    T)r.    W.    .T.    Dodd.) 

liir!<ril  in  tlic  rini:',  llic  pin  is  c-inifd  intn  llie  .-Idniadi  ;ind  allowed  lo 
turn.  Then  tlio  forceps  are  withdrawn  with  the  pin  headed  tiie  otiier 
way.  As  the  pin  comes  into  tlie  tiilie  it  (doses.  The  antiior  lias  ilevised 
a  safety  i>in  tnl)o  the  aim  of  whieh  is  to  dost'  the  pin  and  to  extract  it 
without  lirst  pnshing   it   into   the  stimiach. 

.\  few  years  aRo  the  author  oiiiiinated  an  instniiiieiit  (  l-'ig.  :-'<>•_') 
for  closing  an  ojien  safety  jiiii,  point  up.  The  de\  ii-e  consisted  of  a 
double  broiichdscopi'.  one  tiiiie  iieiim  placed  within  the  other.  The  outer 
fnlie  liad  a  slit  in  the  side  which  eii.iiaued  the  pointe«|  shaft  of  the 
I  in.  liotation  of  the  inner  tube  closed  the  pin.  The  de\-ice  has  been 
^illlplilied    liy    discarding    tin'    inner    iniie.      The    present    instnimeiit    is 


268 


OPERATIVE   Sl'lUiEKY   OF   THE   XOSE,   THROAT,   AXD   EAR. 


made  as  follows:  It  is  the  usual  self-liglited  bronclioscopo.  There  are 
two  sizes,  the  smaller  one  for  the  trachea  and  the  larger  one  for  the 
esophagus.  The  end  of  the  tube  is  bevelled  on  the  side.  Fi-om  the  apex 
of  the  A'  a  slit  runs  upward  about  two  inches.  At  the  summit  and  at 
the  side  of  this  there  is  a  second  smaller  and  connecting  slit.  A  pointed 
tongue  sei^arates  the  two  slits. 

Suppose  for  the  sake  of  illustration  that  the  point  of  the  pin  is  up, 
and  imbedded  in  the  i-iglit  esoi>hageal  wall.     Tlio  tube  is  used  in  tlie 


T'iff.  I'OO. 


.Tackson 's  forceps  for  graspiiis;  and  pusliing  open  safety  pijis  into  the 
stomach  for  turning.  A,  illustrates  point  of  foreeps;  P.,  ilhistiates  method 
of  procedure. 


FifT.  201. 


Schema  showing  Jackson 's  method  of  removing  an  open  safety  piu  from 
the  esophagus  by  passing  it  into  the  stomach,  where  it  is  turned  and  removed. 
The  fir-st  illustration  (A)  shows  forceps  before  seizing  pin  by  the  rings  of 
the  spring  end.  (Forceps  jaws  are  shown  opening  in  the  wrong  plane.)  At 
B  is  shown  the  pin  seized  at  the  ring  by  the  forceps.  At  C  is  shown  the  pin 
carried  into  the  stomach  and  about  to  be  rotated  liy  withdrawal.  D,  the 
irithdrawal  of  the  pin  into  the  esophagosco|ie  wliicli  will  thei'cby  close  it. 
(From   the   Laryngoscope.) 


LAKYXCOSCorY,    UltOXCI  lOSCdPY.    KSOPUAGOSCOPY,    ETC. 


2G!) 


followiiiic  inanncr:  It  is  I'arrii'il  into  the  csopliajjus  until  tlic  iiood  of 
till'  ]iiii  can  Ito  scon.  Tliis  is  irrasiiod  witli  forci'its  and  steadied  wliile 
liie  slit  is  turned  so  that  it  eu,ii:a,ires  the  jjointed  shaft  of  the  ])in.  Then 
llie  tuhe  is  ]»ushed  (Uiwanl  until  the  top  ol"  tlie  slit  hrini^'s  up  aixainst 
the  ci-dteh  of  the  safely  pin.  This  stiiijc  i<\'  tin'  niaiiipninliiins  icached 
the  tube  is  carried  a  little  fnrtlicr  down  in  oiilcr  to  free  tin'  point  of  tlie 
pin  from  the  esophageal  wall.  This  accomplished  tlie  liood  of  the  pin 
is  again  hcM  motionless  by  the  forceps  wiiile  the  barrel  of  the  tulie  is 
rotatetl  to  the  right.  By  tiiis  mani])nlation  tlie  shaft  whicli  bears  the 
l)oint  of  tlie  i)in  is  made  to  lie  in  line  with  the  accessory  slit.  The 
pin  is  now  ])ushed  straight  down  Die  tube.  As  it  descends  the  acces.'sory 
slit,  wiiich  of  course  is  closed  Im'Iow.  acts  as  a  riiiii'  and  sliiits  tln'  pin. 


Fig.  202. 

^^osll('l•'s  safety  |iiii  r<'mo\  iiijr  tube.  1,  eml  iif  safety  jiiii  clo.siiipr  tiil)e. 
2,  Iiood  of  ]iiii  ^.'rasped  tlirou!;li  tul)o.  .'5,  tube  carried  d(i\vii  until  main  slit 
brinuM  up  asainst  llie  crotcli  of  pin.  4,  barrel  of  tube  rotated  to  the  riglit 
in  order  to  brinjj  jdn  in  line  willi  secondary  slot.  .">.  ]iin  pushed  down  and 
closed. 


The  tube  and  the  i)in  are  withdrawn  logi'tiier.  A  moment's  practice 
out.side  of  the  body  \vill  show  tiiat  tliese  niaiii|)uhitions  which  seem 
com]tlicated  when  descril)ed  are  in  reality  very  simple 

Iliil)bard  lias  (levised  a  useful  loop  gni<le  for  the  wire  snare,  and 
'  iiipliiycl  it  >iic(Tssfiill\   fdi-  the  closing  and  removal  of  a  safety  pin. 

Tooth  Plates  in  the  Esophagus.     Toot  1 1  pi.ites.  especially  partial 

I'iates  with  prong.s,  have  the  unpleasant  distiiicti A'  being  the  hardest 

foreign  bodies  which  the  i)liysiciaii  is  called  upon  to  remove  from  the 
e.<opliagu.'<.    .Many  successful  extractions  of  tooth  plates,  however,  have 


270 


<)im:i;ati\e  srr>(ii:r;Y  of  the  nose,  tiikoat.  and  ear. 


been  recorded.  (Fig'.  204.)  it  is  an  axiom  in  dealing  witli  these  difficult 
cases  that  unless  tlie  exti'action  is  fairly  easy  and  is  soon  acconiplished 
tlic  foreiu'n  bodv    should   lie   i-emox'cd   li\-  an   incision  tln'ouuh  tlu-  side 


Fife.    203. 
Moslipr's  safety  iiiii  for< 


of  the  neck.  It  shonld  he  remem- 
bered, however,  that  the  mortal- 
ity of  this  procedure  is  12-20  per 
cent  or  ten  times  the  mortality  of 
esopliayoscopy.  Eough  manipu- 
hilion  is  not  jiermissible.  The 
chief  difticulty  presented  by  these 
eases  is  the  locking  of  the  prongs 
of  the  plate  in  the  tissues.  Some- 
times the  plate  can  be  tui'ned  by 
careful  manipulation  so  that  its 
short  diameter  may  lie  in  the 
direction  of  the  esophageal  axis. 
Killian  accomplished  the  as- 
tounding feat  of  cutting  a  plate 
in  t\vn  bv  galvauocauterv.  Rather 


Fig.  204. 

Tootli   plate   in  the  esophagus.     (Plate  b}' 

Dr.  W.  J.  Dodd.) 


tliau  attempt  to  tni-n  tlie  plate  it 
is  lietter  sni-gery,  unless  the  turn- 
ing should  prove  to  be  easy,  to 
cut  tlie  plate.  For  tiiis  a  power- 
ful forceps  is  necessary.  A  cut- 
ting forceps  has  been  devised  by 
Kahlcr.  The  one  devised  by  the 
author  is  illustrated  in  Fig.  205. 
The  tootii  plate  should  lie  at- 
tacked er.rly,  before  tlie  irritation 
set  up  by  it  has  caused  the  esoph- 
ageal wall  to  become  inflamed 
and  edematous.  When  this  has 
occurred  it  is  hard  to  get  a  good 
view.  Briinings  has  invented  a 
dilating  esophagoscope  for  use  in 
these  cases. 


LAKVXliOSl'OrY.    miOXCimSCdl'V.    KSOrilACOSCOPY,    KTV. 


L'71 


After  all  i'SO|ilia,ii«'al  cNaiiiiiiatioiis.  and  ('s|icciall\  aricr  tlic  iiiaiiip 
iiiatidiis  lu'ccssary  tor  tin-  dilatation  of  a  stricture  m-  Im-  I  lie  iciiKival 
(•!'  a  I'oii'ijin  hody,  tin-  patii'iit  cimiplaiiis  nf  a  sore  tliroat.  Soniclinics 
lliis  is  si'ViTi'  and  niaki-s  tin'  swallowinu;  of  i'liod  dil1ic\dt  Tor  a  IVw  days. 
After  the  stretchini;:  itf  a  stricture  tiifri-  may  Itc  pain  aluiii:  the  course 
of  the  esophai^us  and  shar))  ]iain  in  the  epiiiasti  iuui.  Also  there 
may  he  a  rise  of  temperature  f<ir  t\\  rnty-foiir  hours.  Now  and  tlien 
there  is  emphy>ema  of  the  side  of  thi-  neck.  These  unpleasant  symp- 
toms, whieh,  put  in  persjieetive,  must  he  reyai'ded  as  trivial,  soon  dis- 
apjiear  under  sim]ih'  treatment. 


Fig.  205. 
Mosliei-'s   iiistninuMit    for   outtinjj   a   tootli    )>lat(;   or   hiiKo    pieces 
of    lione.     A    sniiiUcr    instniniciit    of    tliis    same    jiaUi'm    cua    In-    lia<l 
for  (lending  pins  <l(>iil)le  aad  extracting  flicni. 


GASTROSCOPY. 

History. — In  ISSl  ^likuliez.  who  did  so  niueii  pioneei-  work  in 
osopha.i;oscopy,  decided  after  e.\|)erimentation  that  the  .na.strosco])e 
must  1)0  rigid.  The  men  who  had  attacked  the  problem  of  irastroscopy 
liefore  this  time  had  used  instruments  whieh  were  juinlcd.  Mikulicz, 
however,  jdaced  a  hend  in  his  ^astroscope  in  order  thai  it  uiiiilit  accom- 
modate itself  to  the  curve  of  the  vertehral  column.  His  instrument 
was  clo.sed  and  the  picture  of  the  gastric  mucosa  was  jji-oduced  by 
pi"isms  after  the  fashion  of  the  cystoscope.  Hosenhcim  al>i)  worked 
with  a  rigid  tnhe  Inil  he  discarded  the  bend.  Tii  tlu'  construi-tion  of  his 
tube  he  also  nuulc  u>r  u['  lenses  and  prisms.  ll  remaiueil  for  Jackson, 
using  a  straight  instrument  without  optic  apparatus,  to  make  gastro- 
scojjy  feasible  and  comparatively  easy,  lie  elongated  the  esophago- 
scope  of  Eiuhorn  and  adtled  a  drainage  tube  on  the  side,  lie  dem- 
onstnited  tluit  such  an  instrunu'nt  couhl  be  i»assed  into  tiie  stomach 
readily,  and  laid  down  the  axioms  of  modern  gastroscopy,  namely: 
The  gastro'^cope  must  be  passed  by  siulil.  The  stomach  should  be 
examined  in  the  culhipscd  >tati'  In  pciiiiit  cleiiniim  nf  ihc  nmcosa  by 
mopping,  and  \<<  (  naiile  the  operatoi-  to  palpate  the  walls  of  the  stomach 
with  tile  en<i  of  the  instrument,  (ieneral  anesthesia  is  indisix-nsable  in 
tinier  to  present  retching.  When  this  occurs  the  diaphra-m  clnlchcs 
the  tube  and  ilefeats  the  examination. 

Usefulness  of  Gastroscopy.  Mndem  gastroscopy  after  the  method 
of  .l.-K'k-.iii    i-   ;i    r,|;iti\ civ    new    piciei'dnre.   ■.:..   t!i;il    the    p;irt  it   is   to 


2i'2  ()1'i;i;ative  sukgeky  of  the  xose,  throat,  axd  ear. 

l)lay  ill  siu'^'ery  has  not  yet  bet'ii  (lolerminod.  All  endeavor  in  this  line  is 
still  ])ioiioer  work.  "When  tlie  physician  in  making  a  diagnosis  is  able  to 
sulislitute  sight  for  touch  he  has  made  a  gain  almost  too  great  to  meas- 
ure. (Jastroscopy  by  the  Jackson  method  has  actually  done  this.  It 
follows,  therefore,  that  it  is  of  the  greatest  service  in  deteniiining  the 
]n-eseiice  of  cancer  and  in  locating  ulcers.  By  this  method  it  is  possible 
also  to  remove  certain  foreign  jjodies  from  the  stomach. 

The  cry  of  the  surgical  world  in  cases  of  cancer  is,  "Make  the 
diagnosis  early."  "When  cancer  of  the  stomach  is  suspected  let  tlie 
surgeon  therefore  turn  to  the  gastroscope. 

Instruments. — The  gastroscope  of  Jackson  is  a  long  esophagoscope. 
(Fig.  2()().)  Frequently  in  order  to  examine  the  stomach  the  tube  must 
be  80  cm.  in  length.  For  many  cases,  however,  70  cm.  is  sufticieut. 
Such  a  tube  can  be  lighted  satisfactorily  only  in  one  way,  that  is,  by  a 
light  at  the  far  end.  This  means  that  the  tube  must  be  of  the  self- 
lighted  pattern.  The  diameter  of  the  adult  tube  is  10  mm.  Jackson 
states  that  he  frequently  uses  a  tube  wliose  outside  dimensions  are  11 
mm.  in  one  diameter  and  14  in  the  other.    The  distal  end  of  the  tube  is 

. .====. =___= .. ^.^ 


Fig.  206.  \il 

Jaeksou  's  bronchoscope,   csophagoseojie   and   gastroscope. 

made  in  the  form  of  a  thickened  ring  in  order  to  prevent  injury  of  the 
tissues.  The  tube  is  titted  with  an  obturator  the  conical  end  of  which 
projects  beyond  the  gastroscope  and  makes  the  introduction  easier.  An 
elastic  bougie  somewhat  longer  than  the  gastroscope  can  l)e  employed 
instead  of  the  obturator. 

The  Technic  of  Gastroscopy. — General  anesthesia  is  essential  for 
the  proper  i)orformaii('e  of  gastroscopy  and  deep  anesthesia  is  neces- 
sary to  prevent  retching  and  to  relax  the  fibres  of  the  (liai)hragm  at 
the  point  Avhcre  the  esophagus  passes  through  it. 

The  patient  is  given  the  usual  surgical  preparation.  Food  is  with- 
held for  twelve  hours  in  order  that  the  stomach  may  be  as  empty  as 
possible.  "Washing  out  the  stomach  is  not  a  satisfactory  substitute 
for  fasting. 

The  Position  of  the  Patient. — Jackson  in  his  earlier  work  had  the 
patient  placed  on  his  back  and  in  a  position  lialf  way  between  the  Tren- 
delenburg and  the  horizontal  posture.  This  causes  the  fluid  remaining 
in  the  stomach,  and  it  is  never  possible  to  get  the  stomach  completely 
dry  except  by  mopping  through  the  gastroscope,  to  drain  from  the 
stomach  bv  gravitv.    Of  late  Jackson  has  elevated  the  head  of  the  table 


i,.\i!VX(;(ist'(trv.  nl;()^•(•llns(■(ll•^ .  ksopiiaooscopy,  etc.  -io 

after  till'   iiiti-oduction  of  tlii'  tiihc  so  lli.it    1 1 iirr.itor  can   i-xamiiif 

at  his  case.  In  tlic  linal  position,  tlic  lii'a.l  >>\'  llir  laMc  is  alx.nt  I'.d 
<-ui.  lii.u:lu'r  tlian  tln'  foot.  The  assistants  are  jilaeeil  a-  in  lii<ineiioseoi)y 
or  esoi)lia.iroseo|iy.  The  second  assistant  holds  the  inail.  'i'liis  is  a  very 
responsilde  position.  Boyee,  wlio  has  htn.u-  assisted  .laeksoii,  lias  jjiveii 
uiueli  study  to  tliis  detail  ()f  the  examination.  The  followinj?  state- 
ment of  the  method  in  which  the  .second  assistant  should  mana.i-e  the 
liead  is  taken  from  a  detailed  description  iriven  l)y  Boyce.  The  month, 
pharynx  and  esoi)hagus  are  brou,ii;ht  into  a  strainht  line,  not  Ky  ihc 
leveraije  of  the  tuho,  but  by  the  ])osition  uf  the  jialii'iit's  luad.  TIm' 
head  is  held  steadily  in  extreme  extension  ami  tin'  iiioiilli  i>  kcpi  wiilc 
oiten.  The  jaws  are  kept  a^iart  by  a  i^ixii  placed  in  the  left  corner  of  the 
mouth.    The  assistant  who  holds  the  head  also  keeps  the  fjjag  in  place. 

The  patient  is  drawn  toward  the  operator  until  his  shoulders  are 
clear  of  the  oi)erating  table  by  four  or  six  inches.  The  ixivj;  is  inserted 
on  the  left  side.  The  assistant  sits  on  the  right  nf  the  jiatient  on  a  studl. 
His  right  leg  is  held  in  the  kneeling  iiositinn  while  tlic  left  foot  is  sup- 
ported on  a  stool  L'li  inclifs  lower  than  the  tdp  nf  the  table.  The  assist- 
ant's right  forearm  is  jiassed  beneath  the  neck  dl'  the  patient  and 
supports  it.  The  right  hand  grasps  the  ninutli  gag  and  keeps  it  from 
slipping.  The  left  hand  of  the  assistant  rests  on  his  left  knee  and 
gras])s  the  to))  of  the  patient's  head  and  at  the  sanu'  time  bends  it 
baekwaid  and  upward.  The  exact  amount  nf  backwai-d  bend  and  of 
n))ward  pressure  reipiired  is  detennined  liy  experii'Uce  on  the  indi- 
vidual case. 

Passing  the  Gastroscope. — The  gastmseopo  should  be  ])assed 
gently.  If  tlie  tube  does  not  advance  readily  its  position  i-  w  iohl;-  and 
it  should  be  changed.  The  tube  Jiuist  be  well  Inbriealcd  with  vaselin. 
The  gastro.scope  is  grasped  and  held  by  the  right  hand  of  the  operator 
after  the  maimer  shown  in  Fig.  207  (Jackson). 

The  forelinger  of  the  physician's  left  hauil  is  inti-odnced  into  the 
right  ijyriform  fossa  of  the  jialieut  and  tlm  end  of  the  gastroscojie  is 
carried  down  with  the  finger  as  a  guide.  As  the  tube  descends  a  cer- 
tain ainouiii  of  upward  leverage  is  made  with  it  on  the  base  of  the 
t(mgue  and  the  epiglottis  and  finally  on  tlir  cricoid  cartilage.  The 
linger  of  the  physician  can  si-ldoin  feci  t  lif  ciimid  carl  ilage  in  the  ailult. 
This  is  inmiiiterial  because  once  the  end  of  the  gastroscope  is  well  in- 
.serted  in  the  right  pyriform  sinus  it  <lrops  readily  into  the  esoi)liagus, 
jirovided  there  is  no  disease  at  this  point.  Disease  at  the  beginning  of 
the  esophagus  shoulil  have  been  excluded  previously  by  the  ii.se  of  the 

lannigeal  niiiidr.     If  this  has  iio1   1 n  done  it  is  cxcdiided  at   the  time 

by  examination  with  the  speciiluni.    It  is  seldom  necessary  to  pass  a  llex- 
ilile  liougii'  through  t  lie  tulie  and  into  1  lie  esophagus  to  serve  as  a  guide. 


l'(4  oPKr.ATivK  srncKr.v  (iK  the  xose,  throat,  axd  ear. 

After  the  tube  has  slip[)e(l  into  tlic  csoiihaiiiis  the  liend  df  the  pa- 
lic'iit  is  raised  sli,i>'litly,  the  obturator  is  \vith(h-a\\ii  aixl  the  eiineiit  I'm' 
lightiiiii-  is  turned  on.  From  now  on  the  tube  is  ]jassed  by  sight.  Tiie 
csoi)hai;-eal  hnneu  must  be  made  out  ahead  of  the  tube  befoi'e  it  is 
a<l\aueed.  With  eacli  inspiration  the  esojjliagus  oi)ens  and  guides  the 
tube  in  the  right  direction.  The  end  of  tlie  gastroscope  is  kept  in  the 
long  axis  of  the  esophagus,  and  not  pointed  strongly  upward  for  fear 
of  collapsing  the  tradiea.  After  the  iutroitus  has  been  passed  only  two 
points  give  trouble.  The  first  is  tlie  hiatus  of  the  diaphragm,  the  sec- 
ond the  subplirenic  portion  of  tlie  esophagus.  The  hiatus  is  passed  by 
making  the  long  axis  of  the  elliptical  tube  correspond  with  the  long 
axis  of  tlie  liiatus.  The  axis  of  the  hiati;s,  as  has  been  said,  is  oblique 
from  behind  forward  and  from  right  to  left.  It  helps  very  much  if  the 
hiatus  is  partially  nr  fully  chiscd  as  tlie  tulie  approaches  it.    If  it  is,  the 


I'cisitioii    nf    the    ri:4lit    liaiiil    (luriii-    tlu>    iiiti odm-tion    of    the    gastroscope, 
vicwrd  riniii  alii.vc  liv  tlir  operator  looking  dowiiuard.     (After  Jackson.) 

observer  sees  a  central  rosette-like  opening  ahead  of  the  tube.  The 
esophagus  leading  down  to  this  is  smooth.  (Fig.  169.)  The  end  of  the 
tube  is  plac(>d  against  this  opening  and  then  a  little  in-essure  or  a  little 
-deepening  of  the  anesthesia  allows  the  tubt'  to  slip  througli  into  the 
abdominal  portion  of  the  esophagus.  The  picture  seen  through  the 
tube  at  once  changes.  Instead  of  smooth  walls  as  before,  the  esophagus 
is  now  thrown  into  long,  thick  folds  which  center  at  the  left  of  the  field. 
(Fig.  170.)  No  regular  opening  is  made  out,  but  if  the  end  of  the  tube 
is  crowded  to  the  left  and  advanced  slowly  the  folds  part  and  the  irreg- 
ular dark  slit  suddenly  bursts  open  and  the  tube  is  in  the  stomach.  If 
the  cardiac  opening  of  the  esophagus  is  in  a  state  of  spasm  the  long 
longitudinal  folds  of  the  abdominal  esopliagus  swing  fi'om  left  to  right 
and  radiate  from  a  small  circular  o[)cuing  which  is  placed  in  the  left 
(piadrant  of  tlie  Hehl. 


i.AnvNi;osc(t!'v,  itKdNciioscdi'N',  i;s(pi'iiA(;iis(i>i'v,  etc.  '-i-> 

In  order  to  juiss  tlic  ;iliilniiiiii;il  rsopliiiuMis  it  is  iici'i-ssiiry  smiictimi's 
to  hi'iul  the  lii'iid  Mild  lU'ck  of  tin-  luitifiit  lo  tlu"  ri^dit.  Full  JiiicsUicsiii 
is  iiocossary  for  passiiiu:  llic  liiiitns,  tlic  siiliplirciiic  imrtiiiii  of  lln' 
oso])li;i<;ns  and  the  cardiac  (ipcninti'. 

Wlicn  tiic  irastroscopc  has  entered  the  stomach  it  is  necessary, 
owini;-  to  the  small  liehl  yiven  liy  the  tulie,  to  liave  a  system  in  the 
examination.  Then-  are  two  plans  of  exjiloration.  First  the  gastro- 
scope  is  carried  straiuht  down  to  the  greater  cnrvatnre.  inspecting 
on  the  way  a  strip  of  the  anterior  and  tlie  posterioi-  walls.  If  the  stom- 
ach is  not  snlliciently  collapsed  one  wall  must  lie  taken  at  a  tinu'.  After 
the  (irst  strip  has  been  gone  over  the  end  of  the  tulie  is  moved  slightly 
to  one  side  and  brought  up  an<l  a  new  set  of  folds  examined.  This  is 
I'epeated  until  the  jtyhnic  limit  is  readied. 

.\s  much  of  the  slomacli  a-  pns^iiile  i>  e\;nnine(l  strip  hy  strip. 
Tiieii  the  second  nietiiod  of  ixaniination  is  iiraeticed.  This  consists  in 
passing  the  tube  down  to  the  extieme  li'ft  of  the  greater  curvature  and 
then  swinging  it  along  tlie  line  i>\'  the  ureati'r  eurvatiire  to  the  rigid. 
Having  reached  the  right  limit  t  ln'  1  iiln'  is  \\  il  hdraw  ii  a  litt  Ic  and  sw  un:^- 
hack  like  a  iiendnluni.  In  this  way,  id  re.-itini;  steji  hy  step  ami  swing- 
ing the  end  of  the  tube  hack  and  forth  fr(im  rii;lit  \t>  left,  the  examina- 
tion is  continued  until  the  cardia  is  ii'acheil.  Tln'  examination  is 
greatly  aided  by  hax'ing  an  assistant  manipulate  iiy  palpation  the  unex- 
plnicd  p(irli(in>  (if  the  stomach  in  fmnt  of  the  end  of  the  tnlie.  For 
this  jiuriiose  the  patient  may  he  tnined  lir>t  on  one  side  and  then  on 
the  othei'.  During  these  niaiiipiilat  ion>  liic  tnln'  is  withdrawn  into  the 
esophagus  and  then  jiushed  into  the  stomacli  again  when  the  new  jtosi- 
tion  of  the  patient  has  been  ad.jnste*!.  if  the  patient  begins  to  retch 
wjien  the  Inbe  is  in  the  stomacli  it  is  w  it  lidiaw  ii  into  the  esophagus 
above  till'  diaphragm. 

The  vertical  diameter  of  the  stomach  is  deteimined  by  nieasure- 
nieiit.  The  distance  from  the  teeth  to  the  caidia  is  ascertained  and 
then  the  gastroscope  is  iiu>lieil  down  to  the  urealer  eiir\alni'e  and  the 
distance  from  the  teetli  determined  auain.  The  diffeieiiee  between  the 
two  measurements  is  the  \-ertieal  diameter  ol'  ihe  >tomach.  in  these 
manipulations  it  is  necessary  to  ;i\-oid  pn^llinu  the  greater  eurxaturc 
<lownwaril. 

The  smallest  vertical  diameter  found  by  .lackson  in  an  adult  was 
4  em.  (one  ami  one  half  inrhcv)  and  the  greatest  .')(>  cm.  (fourteen 
liichiv-  ). 

The  end  of  tlu'  tuhe  tend-  to  drai;-  the  stomacli  walls  along  with  it. 
This  can  be  avoided  by  withdraw  iim  the  tube  a  little  and  then  carrying 
it  down  again.  The  average  time  i(M|irnc(|  to  examine  the  stomach  is 
thirtv  miiniti's. 


_'(()  OPKIIATIVE    SriUiKllV    OI'    T 1 1 K    .\(.)SK,    TliliOAT,    AM)    EAR. 

The  Area  of  the  Stomach  Which  Can  Be  Explored. — Vertical  and 

iiiraiitile  stomachs  afford  the  greatest  ranye  of  ex|iloratioii.  The  more 
liorizontal  the  stomach  the  less  the  range.  The  lateral  movement  of 
the  hiatus  makes  it  possible  to  examine  the  stomach  over  an  extended 
area.  This  lateral  movement  varies  with  the  individuah  It  is  greatest 
in  feeble,  elderly  and  emaciated  patients.  Also  the  deeper  the  anes- 
thesia the  greater  it  is.  The  anteroposterior  mobility  of  the  hiatus  is 
of  but  little  use.  If  the  diajjliragm  were  rigid  gastroscopy  woidd  be 
much  limited.  ( )wing  to  its  flexibility  the  end  of  the  tube  can  be  made 
to  pass  at  the  hiatus  through  an  elliijse  the  small  dianu^ter  of  which  is 
5  cm.  and  the  large  diameter  15  cm.  The  long  axis  of  this  ellipse  is 
placed  laterally. 

The  full  range  of  the  thoracic  aperature  is  made  available  by  shift- 
ing the  iiead  and  the  neck  to  the  side.  The  pivotal  or  rocking  i)oint  of 
the  gastroscopc  is  in  the  thorax  not  at  the  lieginning  of  the  esophagus 
or  at  the  hiatus. 

As  a  rule  the  tube  can  be  made  to  ijoint  in  turn  to  either  superior 
spine  of  the  ilium  and  the  greater  (nir\atnre  can  be  forced  down  to  this 
level. 

Any  anomaly  or  disease  of  the  esop)hagus  may  render  gastroscopy 
dinicult  or  im|iossible. 

Contraindications. — Tlie  contraindications  to  gastroscopy  are  tho 
usual  conditions  Avhich  make  the  giving  of  an  anesthetic  unsafe. 

Dangers. — The  dangers  of  gastroscopy  in  careful  hands  are  only 
the  risks  of  the  anesthesia.  The  observations  of  Boyce  show  that  the 
blood  pressure  falls  when  a  rigid  tube  is  introduced  into  the  esophagus. 
This,  however,  lasts  only  a  short  time.  As  esophagoscopy  and  gastro- 
scopy are  done  by  sight  there  is  less  danger  than  in  the  passing  of  a 
sound. 

Difficulties. — Any  physician  who  has  had  a  training  in  the  use  of 
the  microscope  can  look  through  the  gastroscope  and  see  tlie  j^icture 
which  it  presents.  If  he  has  not  had  this  training  it  takes  a  little  time 
for  him  to  teach  his  eye  to  see. 

Lordosis,  Potts'  disease  and  other  diseases  of  the  spine  make  gas- 
troscopy impossible. 

The  Stomach  as  Seen  Through  the  Gastroscope. 

The  Normal  Stomach. — The  folds  of  the  stomach  arc  constantl\- 
changing  so  that  no  two  views  are  alike.  When  the  gastroscope  enters 
the  cardiac  opening  the  folds  extend  straight  on  from  the  mouth  of  the 
tube  and  a  small  tunnel  of  open  stomach  is  seen.  As  the  tube  is  carried 
down  through  this  the  folds  take  a  lateral  bend.  Finally,  the  tube 
brings  up  against  the  stomach  wall.     This  appears  as  a  flat  surface 


l.AKVNtiiiSl'dl'V.    lilloMllnsCiil'V,    l.snl'l I AfiOSCOPY,    ETC.  -(i 

wliifli  IS  soiiictiiiii's  iiiciltlril.  s(iiiu'tiiiu-s  sli.iilitly  rril.  Tin  uri-atcr 
<nirvatuir  alli>\vs  tin-  tiilic  lo  piisli  it  (lowiiwanl  sonic  in  ini.  iict'orc 
it  resists.  ^Viu'Il  tin-  tiilic  is  witlulrawii  tlic  sluiiiacli  wall,  wlii -li  lias 
1)0011  flattoiioil  a.yaiiist  it  I'ttilows  tlio  tul)o  uiiwanl  tn  the  ii(i>itinii  wlinc 
tiio  tubo  lirst  oiioountorod  it  or  a  littlo  liii-lior.  As  yot  not  fiioii.uli 
is  known  aliont  tlio  aiTaiijicnionl  ol"  llio  folds  to  atlonipl  to  ^loui) 
thoni. 

Tlio  imu'osa  of  tlio  osoplia.mis  and  that  of  liio  stuniacli  at  tinios  are 
strongly  contrasted  in  color.  The  color  of  the  esoiihagus,  however,  is 
more  constant.  Tlii>  osoiiliamis  is  a.-enornlly  a  pale  ])iiik  wlicroas  tlio 
mucosa  of  the  stoiiiarh  \-;iiir-  fi-oiii  a  similar  |iiiik  In  a  (lri')i  criiiisdii. 
.lackson  considers  that  tlio  color  of  the  oinpty  stoinacli  varies  i'vmw  .1 
pale  red  to  a  jialo  jiink.  The  nincosa  ajjpoars  moist  and  iili stoning  Init 
loss  transparent  than  the  iiuirosn  of  the  esophagus.  In  the  walls  nf 
the  empty  stomach  vessels  arc  unt  usually  visible. 

The  i>ylorus  is,  of  course,  found  mi  the  rinlM  cxticmity  of  tin' 
greater  curvature.  As  the  lube  appniadics  the  folds  guardin.i;  il.  il 
seems  like  a  slit.  Tliis  gives  way  wiien  the  tube  has  fully  icaclicd  the 
opening,  and  a  round  opening  appears  soiuowhat  like  the  rosette  made 
by  the  esophagus  at  the  hiatus.  The  oiiservci-  makes  sure  that  the 
opening  is  the  jjylorus  by  advauciiiL;  tin'  tube  iiitn  it  until  the  small 
annular  folds  of  the  duodenum  come  into  \irw.  If  bilf  mlored  Huid 
escajjos  njjward  at  this  ])oint  the  hieali/alimi  nl'  tlie  pylmii-  opeuing  is 
determined  1)eyond  a  doubt. 

The  Movements  of  the  Stomach. — Beside  tiie  ordinary  peristaltic 
movements  nf  the  sloiiiaeli  thei-,'  arc  movements  associated  with  the 
heart  and  with  re>piratinn. 

The  movcnu'iit^  transmitted  frnin  the  heart  are  best  seen  just  as 
the  tube  enters  the  cardia.  They  come  from  the  heart  and  the  descend- 
ing aorta  and  are  syuclii-nnou^  with  the  beat  of  the  heart  and  the  Idood 
wa\'e  in  the  aorta. 

The  respiratory  movements  in  the  stomach  are  loss  maiked  than 
in  the  esophagus.  Just  as  in  the  oso]iliagus,  there  is,  in  hirii,  a  nega- 
tive and  a  |io>iti\<'  in-essurc  'i'liis  alteration  causes  an  iiillow  and  an 
(jutflow  of  air. 

Tltc  Peristaltic  Moroiioits. — The  piiistali  ic  ni(i\-eiiieiits  of  the 
stomach  wliich  result  from  the  aelion  nl'  \\~-  own  lilnes  can  be  fre- 
quently si'oii.  These,  however,  are  not  as  iiiarkeil  as  the  antiperistaltic 
movements.  The  latter  are  of  two  kinds,  the  rovorst-d  ])crislaltic 
movement,  which  is  seen  mostly  at  the  I'undus  and  causes  vomiting,  and 
the  antiperistaltic  movement  of  the  ilnmlciial  \aiiety  which  is  confined 
to  the  region  of  the  pylorus. 

Tlie  pvloric  third  of  the  -toinacli  is  the  nio>t   unstable  part,     .lack- 


278  OPKRATIVE   SURGERY   OF  THE   XOSE,   THROAT,   AND   EAR. 

son's  descriijlioii  of  tlio  a])ci-tui-e  seen  tliroun-li  tlio  tube  as  it  cii)proaches 
tile  pylorus  states  that  in  (Hie  instaiici'  the  pylorus  was  surrounded  by  a 
rosette  of  annular  folds.  In  anothei',  the  folds  were  larii,er.  These 
curved  in  ahead  of  the  tube  and  then  Avere  pushed  aside  by  it.  Fiiudly, 
one  large  fold  was  encountered  and  when  this  was  thrust  aside  a  slit 
came  into  view.  Tliis  chaiiiied  at  once  into  a  rounded  opening  Avhicli 
was  the  entrance  to  a  shoi1  tunnel  in  the  lumen  of  which  there  were 
numerous  small  folds.  From  this  ui)ening  and  the  tunnel  beyond  some 
bile-like  fluid  welled  up. 

Gastritis. — Jackson  tlms  describes  the  gastroscopic  findings  in  a 
case  of  gastritis.  The  walls  of  the  stomach  were  covered  with  a  thick 
past}'  secretion  and  tlie  folds  were  thickened.  In  another  case  the 
secretion  was  in  patches.  In  still  another  case  the  color  of  the  mucosa 
seemed  darker  red  than  the  normal.  In  only  one  case  did  this  observer 
find  dilated  capillaries  such  as  are  seen  in  chronic  inflammation  of  the 
esophagus. 

Peptic  Ulcer. — Jackson  has  had  the  courage  to  examine  the  stom 
acli  in  cases  of  ulcer.  He  reports  his  findings  as  follows:  The  first 
ulcer  was  a  dirty  grayish-yellow  and  was  not  i)unched  out.  The  ulcer 
of  the  second  case  was  punched  out  and  had  slightly  infiltrated  edges. 
In  another  case  the  ulcer  appeared  as  a  longitudinal  slit.  In  still 
another  the  bed  of  the  ulcer  was  dark  and  rough. 

Malignant  Disease  of  the  Stomach. — Malignant  disease  of  the  stom- 
ach gives  a  \arying  jiieture  in  <litVerent  parts  of  the  stomach  and 
in  different  parts  of  the  same  growth.  There  is  a  striking  contrast 
between  the  nuicosa  over  a  cancerous  infiltration  and  the  normal 
mucosa.  Over  the  growth  the  nornud  fohls  disappear  and  the  surface 
of  the  lesion  is  irregular,  granular  or  nodular.  In  most  cases  secretion 
covers  the  site  of  the  growth.  The  growth  varies  in  color  from  white 
through  gray  and  yellow,  to  pink,  red,  crimson,  purple  or  brown. 
Malignant  disease  gives  the  best  i)icture  for  diagnostic  purposes  when 
the  growth  has  reached  the  fungus  stage. 

When  the  mucosa  is  infiltrated  but  unln'oken  the  tube  can  be  used 
to  palpate  the  growth  and  to  determine  the  extent  of  the  infiltration. 
In  this  way  the  growth  may  be  pushed  up  to  the  abdominal  wall  and 
made  accessible  to  external  pali)atioii.  Tlie  sense  of  touch  transmitted 
through  the  tuV»e  is  a  great  hel])  in  ujaking  the  diagnosis  of  malignancy. 

Gastroptosis  and  Gastrectasia. — The  position  of  the  greater  curva- 
ture and  the  vertical  diameter  of  the  stomach  are  easily  obtained.  The 
position  of  the  pylorus  is  essential  in  order  to  distinguish  between  an 
enlarged  stomach  and  a  stomach  displaced  downward.  If  the  stomach 
is  of  the  infantile  variety  the  position  of  the  lesser  curvature  is  easy  to 
make  out,  otherwise  it  is  not. 


(  ii.\i'Ti;u  \i. 
I'l  \ST!C  SIRCKRV  OF  TIIK  NOSK  AND  i;\R. 

iiy  Jnsi-|i|i  «   .    I'MM-k,   .M.    h. 

General  Considerations. 

The  linrdciiiiu'  ol'  nciicral  sur.^ciy  ;iii<l  ()l()lar\ii.u<>l<).i;>'  i>  >■'•  inilis- 
tiix't  by  reason  of  the  (.'vidciit-o  ["nniislu'il  hy  tlu'  slu(]y  of  this  sul),iL'ct 
that  there  is  some  (luestioii  as  to  wliere  it  riiiiitt'iiUy  belongs.  It  is  tlio 
<-onviction  tliat  tlie  larynuohigist  and  otologist  have  the  greater  elaini 
tliat  impels  tlie  author  to  treat  this  subjeet  from  the  sjieeialist's  stand- 
]ioint.  The  otolaryngologic  surgeon  is  l)etter  (|uali(ied  to  do  this 
work  simply  because  he  is  so  Avell  informed  on  the  re(|uirements  of 
these  structures  from  tlicir  anatomic  characteristics  and  their  physio- 
logic functions.  Cosmetic  considerations  do  not  constitute  the  sole 
reason  for  the  performance  of  these  o]ierations. 

The  deformities  or  malformations  which  call  for  ])lastic  i)roced 
ure  may  lie  real  or  imaginary.  The  latter  comprehend  slight  devia- 
tions from  the  iiDinial,  \i  ry  much  exaggei'ateil  liy  the  imlixidnal,  on 
account  of  wjiich  the  jiatient  liecomes  the  ))ati-()ii  of  the  lieaut\  doctor. 
The  ]isychiatrist  would  he  of  moi'e  serxiee.  ()iily  real  (leri.iiiiities  or 
nialfornuitions  are  consicleicd  in  this  eliapler.  Kach  case  is  a  law  unto 
it'^elf  as  to  the  teclniic,  ye]  many  \arieties  and  iiiodilications  of  meth- 
nds  must  be  descrilied.  Tlie  jmrpuse  here  i-  tn  illustrate  r;itliei'  lli;ni 
to   give    e.xtensive    deseliptidUs    nf    (lelinite    nietllnds. 

History. — Keconsti'uetive  snri^ery  with  special  rcferenci.  id  i-hiim- 
plastic  operation  dates  back  tn  llie  piiMications  of  Tagliaco/.zi  in  l.'ili? 
(Figs.  208  to  •2-22)  althoimh  earlier  repoils  of  |)lastic  surgery  of  the 
face  were  said  to  have  been  inade  hy  lleiiedietus  in  14IL'.  Taglia<'ozzi  "s 
work,  however,  \\a~  nnt  taken  np  \er\  entlinsiasticall\  nntil  about  the 
eighteenth  century,  when  a  large  numbei-  of  snr-cons  ivc(igni7.e<l  the 
value  of  this  branch  of  surgei'.w  Since  iIkmi  important  contributions 
have  been  made  by  K'usrn-lein.  hiiliois,  I'.uvcr,  ("arpeie.  ('.  Craefe. 
Balfimr,  Zeis,  l!iiii-er.  I  lelVacker.  W'anvn,  1  JietTeidiaeli.  I'.lan.lin.  lo.ux, 

Serre,  Jobert,  :VInt1er.  l'..-t.  I'; na>t.  I'.nck.  Andrew-.  I'linc.  i;,,herts, 

Koenig,  Israel,  .loseph.    I.an-enlieck.    Olliei-.     Xi'lalon,     Kee-an,     h'oe. 


280 


OPERATIVE   SURGERY   OF  THE  NOSE,   THROAT,   AXft   EAR. 


V\iX.    I'll. 


^i-.  1^1. 'l. 


Fig.    215. 
Illustrations  from  Tagliacozzi 's  work. 


Fig.    216. 


ri,.\>iii    >i  Kcr.itv  oi'  TiiK  xosi',  and  kau. 


281 


Siiiitli.  Kolk',  lu'ViTtliii,  Wolt'i'.  KiMiisc,  'I'lilcrsrh.  (icrsmiN,  Li'mt,  ( \-ir) 
I'xck  ami  many  otlu'is. 

Indications.  In  i-onsi.li'i-iiiL;-  thr  in.ii(;iiinii>  Im-  pl.-istic  sii !•;••(-•  ry  of 
llu'  iKisc  ami  llir  car,  \vi'  liavc  in  iniiid  llir  curiii'lidii  nl'  defects;  first 
for  tiio  ro-i'stalilislmiciit  nf  ccrtaiii  riiiifli(iii>,  sin-li  as  n-sjiiratioii,  plioiia- 


Fig.   21S. 


Fig.    210. 


Fig.   220.  Fig.   221.  Fig.   222. 

Appliances  and  instninicnts  cmiiloycd   liv   Tagliaoozzi. 

tioii,  de.iJ^liititioii,  audition;  and  sci-ondly  for  cosmetic  reciuirements. 
Of  tlie.<e  (lie  former  ]»iiiiiosi-  i>  liy  far  llie  most  im|)oilaii1  from  the 
operator's  point  of  view,  bnt  llic  latin-  is  oft.'ii  of  -icalcr  interest  from 
lliat  of  the  patient.  At  the  same  lime  llie  eosiiielic  iuilication  must  not 
lie  undervalued,  as  by  reason  of  deformities  and  malformations  many 
unfortunate  individuals  arc  <liMiiiM|  (.(nial  (•]innc(>s  and  prixileu-es  in  life 


282  OI'KKATIVIO   Sl'KtiERY   OF   THE   NOSE,   THROAT,   AND   EAR. 

w  itli  their  fellow-inaii.  It  can  l)e  stated  uiiliesitatiiigly  tliat  even  wlieii 
the  licst  results  are  obtained  cosmetically,  the  patients  are  still  much 
liandicapped  by  their  appearance,  since  such  results  still  leave  them 
ol)jects  of  curiosity  and  comment.  This  of  course  is  more  especially 
true  of  extreme  deformities  of  tlie  nose  and  ear. 

The  so-called  better  classes  are  annoyed  by  certain  minor  deformi- 
ties, malformations  and  blemishes  which  injure  their  jjride,  ])nt  which 
otherwise  are  of  little  consequence.  However  good  a  result  is  achieved 
by  the  operation,  the  patients  are  never  entirely  satistied,  and  persist 
in  their  desire  to  have  more  work  done.  These  unfortunates  mostly 
self-centered  and  neurotic  individuals  become  the  prey  of  the  so-called 
"beauty  doctor,"  and  many  bad  consequences  result  from  the  unscien- 
tific surgery  of  the  latter. 

It  is  best  to  attempt  to  discourage  them  from  having  plastic  oiiera- 
tions  performed;  furthermore,  great  care  should  be  exercised  when 
operating  on  them  to  have  the  patients  or  their  immediate  family  as- 
sume all  the  responsibility  as  to  the  cosmetic  results. 

As  a  preliminary  to  the  performance  of  plastic  surgery  it  is  neces- 
saiy  in  order  to  obtain  the  best  results  to  ascertain  whether  or  not 
some  general  or  local  pathologic  condition,  such  as  lues,  tuberculosis, 
general  anemia,  malnutrition  is  present.  These  are  among  the  most 
frequent  causes  of  failure.  A  local  chronic  skin  infection,  as  eczema 
or  graniiloma,  will  retard  or  ju'event  healing  even  if  the  plastic  has 
been  perfect. 

Important  Factors. — Since  there  are  so  many  varieties  of  deform- 
ities there  are  naturally  a  great  many  procedures  for  their  correction. 
After  all  it  remains  for  the  individual  operator  to  use  his  judgment  as 
to  the  selection  of  a  particular  type.  Again,  frequently  a  plan  must  be 
changed  during  the  operation  and  an  entirely  different  i)rincii)le  ap- 
jdied,  or  perhai)S  a  combination  of  diiferent  principles  ov  operations 
must  be  adopted. 

It  is  of  great  help  to  know  the  condition  and  position  of  the  struc- 
tures previous  to  the  deformity.  If  this  has  existed  from  birth,  the 
normal  condition  of  the  parts  should  be  known.  This  is  especially  im- 
portant in  nasal  and  ear  plastics.  For  instance,  in  constructing  a  nose, 
the  surgeon  is  veiy  fortunate  if  he  can  obtain  a  photograph  taken  be- 
fore the  deformity  was  acquired.  Sometimes  photographs  of  the  closest 
relative  who  is  known  to  have  resembled  the  ])atient  before  injury, 
are  of  great  service.  To  make  a  nose  of  the  Roman  style  when,  as  a 
matter  of  fact,  the  patient  had  a  short  stubby,  thin,  straight  or  bulbous 
nose  before,  would  be  ignoring  an  inqiortant  jirinciple. 


iM.ASTic  sri;(;i'.i;v  oi     iiii:   nosk  anh  i;,\i;. 


•JS3 


Tu  cm-  |iliist'u'  tlic  ()|i|Misitf  v:w  niny  lie  used  ;is  a  inmlcl.  In  tli.' 
in.ijiiiity  1)1'  iiistaiK'cs. 

Tlir  selection  of  the  inellm.l  .if  npeiatixc  procetiuri'  is  iiiituially  (if 
"■Teat  iiniiortance.  A  ilelinite  rnle  canndl  always  l)e  laid  down  since, 
as  has  boon  saitl.  each  case  is  a  law  iinln  itsell'.  and  ihe  dpi  ratiiMi  indi- 
cated varies  Avitli  the  a.iic,  condition,  and  \dcation  of  the  |iatient.  A 
rule  Avhioli  tlio  writer  has  rolloweil  is  to  ein|iloy  at  lirst  a  inethoij  in 
volvini;-  ni)  loss  of  tis>ne,  an<l  con-eiineiil  l\  no  additional  deloiniity  in 
ca>e  of  I'ailnre.  in  other  wcii'd-.  it  i-  hot  to  foiiii  the  na>al  >tiin-lnre 
liy  employing-  traiisplaiitalion  method-  in  prelereiiee  to  n>inL;  llaps 
from  the  face  or  I'orcdiead.  Similarlv  intranasal  are  to  he  preferred 
to  external  methods. 

Flajis  should  he  i'i-operl\-  ,-electeil  and  pn'paied.  'I'hey  >honld  he 
niea-nred  ont  previons  to  the  operation,  one  third  larizer  tliaii  the  de- 
fect, and  made  very  plastic,  that  is,  with  not  too  niucli  UHilerlying 
tissue.  Making'  them  too  thin  or  devoid  of  suhcnlaneous  tissue  is  even 
a  lii'eater  mistake,  since  their  iionrishmeiit  is  thns  likely  to  he  affected. 
It  is  necessary  in  make  their  pedicles  eoiit'orm  to  the  hlood  -apply: 
that  is,  to  construct  the  flaps  so  that  the  i; renter  diameter  of  the  vessel 
is  in  the  jK'dicIe  and  not  in  the  jieripheiy.  If  the  pedicle  is  too  ifreatly 
twisted  sti'annidatiou  of  the  Haps  may  occur. 

While  jierfect  cleanliness  or  asejisis  is  practically  impossil)le  in 
inisal  surg'cry,  uii'at  care  vlnmld  he  taken  not  to  introdnce  foreiu'ii 
micro(">r<ianisms  into  liie  wound. 

'I'lnn-on.n'h  removal  of  diseased  tissues  as  well  as  of  cicatrices  is 
ipiite  as  important  as  the  fr(^e  tuidermininu-  of  the  horders  of  the  wcnuul. 
I'atcln's  of  skin  m  mncons  mendnaiie  must  he  dissected  mit,  since  the 
I'etentioii  of  nests  and  the  aecumnlation  of  epithelinm  may  )ire\eiit  a 
Udod  residt. 

Covering  Defects.  It  is  ad\isalile  to  study  the  principles  which 
ti-o\i'in  the  cox'eiinii'  of  coiiucnital  or  cieated  defects.  1  )ielTenhae!!, 
l.anueidieck  and  others  hax'e  de\-eioped  this  suhjeet  to  such  an  extent 
that  almost  an>'  form  and  si/e  of  defect  in  the  skin  may  he  co\-ered  with- 
out causin.ii-  a  marked  deformity  in  the  i-e-ion  fmni  which  the  tissues 
are  taken. 

1.  Defects  may  he  coxcred  hy  makin--  incisions  in  certain  direc- 
tions and  unitiiiu-  in  the  op|iosili'  ilirection,  thns  hioseuin<>-  the  tissues 
ami  uuitinii-  them  in  the  iiest  |iossilile  manner  so  that  the  tension  is  the 
sli.i^htest.  Connter  incisions,  to  relax  the  tissues  ami  to  facilitate  easy 
approximation    of   the   skin,   are   also    freipiently   employe.l.      I^'ii;'.   223 

dc nstrates  various  shapecj  defects  and  the  method  ,,['  co\-eiini;-  them. 

The  arrows  in<licate  the  direction  in  w  hicli  tin'  llaps  shonid   he  turned. 


284 


OPERATIVE    sriUIEHY    ()!•'    THE    NOSE.    THKOAT,    AM)    EAR. 


2.     Skin    Graftiiu). — A,    Kcvt-nliu;    B,    Tliici-scli ;    (',     WoU'c    or 
Krause;  D,  Epithelial  sin-oa<l. 

(A)   The  Eovordin  mothod   is  to   raise   a   small   hil    of  cpidcnius 


W7/ 


I ' 


'  I '  1 1 1 1 1 


//:; 


M  U  .  M  M 


X 


y 


1     '      '      ' — ' — ' >s. 

'S 1 1 1 1 1  r 


Fig.  223. 
Incisions  and  flaps  for  closing  defects.     (Celsus.) 


ri.Asiic  sii;i;i:i;\    ni     rm;   nh-i-.  axp  KAn. 


285 


by  iiu'.ms  of  ;i  iict'dlt',  snip  it  olT  w  itii  kiiil'c  nr  s<-is>iits  jiihI  jilacc  it  over 
tlio  |irci)ariHl  irramilatin.y:  siiri'ari'.     (Fins.  ■_'"J4  and  -'2').) 

(B)   TliiiTSfh    n'rafts    arc    ohtaincil    citin'i-    from    llif    ar •    ii'ii' 

(fvoTn  i)arts  containint;-  little  iiair)  hy  placinu-  the  >l<in  on  a  >tirti-li  and 
em])h)ying  a  very  ici'i'n  razor  or  special  knife,  i  h'iL;.  I'l^il.)  With  a 
steady  side  to  >ide  nioxcuH-nt,  tlu'  epidermal  layer  is  ciil  off  and  foldc(| 
on  the  knife.  Hy  means  of  this  knifi'  the  uraft  is  carried  over  to  th<' 
granidatin.!.;-  area  to  he  eo\-ere(l,  and  liy  the  aid  of  a  neciHr  it  is  laid  and 
spri'ad  out  on  the  liefeet.  I'articnhir  attention  is  paid  to  the  nnirtrins 
of  the  nraft.  so  that  tliey  arc  thoron^ldy  spread  "\\\.  and  noi  i-oHeil  in. 
Tliis  should  he  done  as  carefnlly  as  when  piepaiiiiL;  a  niiei-oscopie 
s]ieeinien.     The  next  uraft  shonld  not   lie  applied  too  idose  to  the  lir-t. 


Fig.   224. 
Making;   Rcvenliii   yrat't. 


Revcidiii   i;ralt   apijliiil. 


ami  so  on,  since  the  cpidcimis  yrows  (piite  readily  from  tlie  mai-.uins 
and  liiiis  hridi^'es  o\-c|-  iikh'c  easily  than  when  the  grafts  are  |ilaeed 
too  close  to  one  another.  The  ui-afts  shonld  not  he  loo  lariie,  since  those 
do  not  snrvi\-e  as  well  a-  small  ones.  Aftci-  the  entire  defect  is  covered, 
the  lirafls  ;ii-e  held  to  liii'  l;  I  a  1 1  iHa  t  i  n  i;  sniface  hy  means  cither  ol' 
strips  of  paralhn  oi-  of  riihber  tissue  in  the  f(n-m  of  lattice  work. 

(('I  Wolfe  oi-  Kranse  nrai'ts  are  transplantations  ol'  the  entire 
skin,  that  is.  of  .■pitlndinm  and  coi'inm.  These  slioidd  he  devoid  of 
very  nmcli  snhcntaMcniis  fat  and  -honid  not  he  toe.  lari;e.  since  their 
vitality  is  nineh  interfered  with  when  they  ai'c  of  more  than  one  half 
inch  in  size.  These  particle-  uf  skin  nia\-  contain  hair  w  he|-e  such  is 
re(piired,  as  f(n-  the  foiniatiim  of  I'yi'hi-ows  or  on  the  n|ipei-  lip  in  the 
m;de.  to  form  a  ninstache. 


286 


OPKItATIVK    SmUKItV    Ol'    THE    XOSE,    THROAT,    AXD   EAl!. 


(D)  Epitlit'lial  (Aussaht)  Spread.  Hy  moans  of  a  i-a/.m'  tlic  sur- 
face e))itlieliuni  is  scraiied  until  a  slight  oozini;-  of  senim  (Imt  not 
lijoiiil)  occui's,  and  then  this  sciapod  oil'  cpilhclinin  is  siiicaicd  mi  llic 
i;Tanidatin.n'  surfaces  in  a  xcry  thin  layer.  It  is  liest  eux-iTcd  witli  a 
thin  layer  of  paraffin  before  covering'  with  gauze  and  bandage. 

Recording  Cases  Before,  During  and  After  Correction. — As  has 
Ix'cu  stati'<l  it  is  best  in  all  cases  to  obtain  a  photograph  of  a  ]iatient 
Itefore  the  occur i-ence  of  the  deformity.     This  will  give  tiio  operator 


Fig.  2-2i). 
Making  and  applying   Tliiersfli  graft. 

tlie  advantage  of  reproducing  as  nearly  as  possible  the  original  con- 
dition of  the  parts.  If  no  photograph  is  obtainable  or  if  there  be  a 
congenital  defect,  the  operator  will  be  called  upon  to  use  his  judgment 
in  the  reconstruction.  This  should  be  in  conformity  with  tlie  rest 
of  the  features  and  facial  expression.  It  is  necessary  to  know  that  a 
broad  face,  which  is  known  as  the  euiygnathous  variety,  will  recjuire 


PLASTIC    srilCKKV    OK    TIIK    XdSK    WIi    KAII. 


287 


a  I'liniinlinii  nr  rt'ciuislnict'uui  ol'  a  lii'iiatlcr  ii<i>r  than  il'  tin'  face  is 
IM-dtniilinL;-,  nv  dt'  the  prnn-natlmus  lypo.  Aii'aiu.  if  llic  face  lie  nl'  the 
luui  ]irntni'iiiiu'  xarirty,  cu-tlioiriiatlunis.  a  short    ikisc  is  licst   suited  to 

it.       I  li'of.  1 

i'lie  next  stop  is  lo  ol)taiii  a  very  (k'taileil  liistory  and  to  iiiako  a 
thoi(iii<;li  local  and  goiu'ral  examination.  Intranasal  and  pharyn.iical 
inlianiniatiny  and  ohstrnctinji'  conditions  ninst  1)0  noted  as  ■well  as  tlio 
local  patliolotric  cliai\ucs  that  may  Ite  ]iresent  on  the  external  nose  or 
ear.  As  to  tiie  i;ciiiTal  ciiiiilil imis  cxistinu'.  syphilis,  t ulicrcnlosis,  severe 
anemia,  and  maliiiitritinn   iiiu>t   ircrixc  tln'  stiidi'sl   recognition. 


Fig.  227. 
Stereoscopic  pliotograj)!!  of  plaster  cast. 

A  nnmber  of  i)hoto.irraplis  from  every  angle  should  lie  taken.  The 
author  is  now  accustomed  to  take  stereoscopic  piiotogi'aplis,  which  are 
avast  iiiiproxeiiieiit  ii\ei-  the  siiiizle  exposure,  since  they  liring  out  much 
more  clearly  the  \arious  tlelects,  liowever  small  they  may  be. 

Plaster  casts  (Fig.  227)  are  excellent  positive  records  of  tlie  con- 
dition i)resent.  Tlu'  rollowiug  method  is  used  i'oi'  making  casts:  Fill 
a  one-half  pint  howl  iialt'  full  with  tepid  watiT  and  plaster  of  Paris 
(dental)  until  the  latter  is  submerged.  I'onr  off  excess  water  and  stir 
to  proper  consistency.  When  one  desires  ipiick  setting  of  the  jilaster, 
a  piucli  of  table  salt  is  introduced  into  tin'  warm  water  before  th(>  plas- 
ter is  added.  Before  a))plyini:-  it  to  the  lace  a  line  iayei-  of  vaselin  is 
spread  upon  the  skin  ami  the  anteiior  nare>  or  tiu'  nasal  apertures  are 
plugged    loosely   with  cotton.     A  small    rubber  tube   is   kejit    I'eady  to 


288 


OPERATIVE   SURGERY   OK   THE   XOSE,   Tlli'.OAT,   AND   EAlt. 


plnco  into  the  patient's  mouth  at  tlic  hist  nionicnt,  just  before  tlic  jihis- 
ler  is  put  over  the  mouth,  in  or(h'i-  thai  the  jiatient  may  breathe  whiU' 
the  ])hister  hardens.  The  mask  is  begun  by  phacing  the  plaster  in  tliin 
layers  a!)out  the  forehead  over  the  closed  eyelids,  cheeks,  lower  .jaw, 
nose,  u]3per  lip,  lower  lip,  and  closely  about  the  tube.  This  tirst  layer 
is  reenforced  with  a  goodly  quantity  of  plaster  and  the  mask  is  allowed 
to  liaidcii.  The  subject  should  avoid  any  facial  movements,  in  fact  he 
should  lie  jterfectly  still  until  the  plaster  is  set,  which  takes  usually 
from  three  to  five  minutes  after  the  mask  is  finished. 

The  removal  of  the  formed  mask  is  now  veiw  carefully  manipu- 
lated so  that  it  may  come  off  in  toto.  If  it  should  unfortunately  bi-eak 
into  two  or  more  parts,  it  is  carefully  placed  together  and  cemented, 
as  is  done  by  the  dentist  in  making  jilaster  casts.  In  fact  this  whole 
procedure  is  so  much  like  the  making  of  dental  impressions  that  the 
author  would  recommend  that  a  dentist  be  emiiloyed  for  the  ])urpose. 
To  make  the  positive  from  this  mask  is  the  next  procedure,  and  this  is 
accomplished  by  painting  the  inner  surface  of  the  thoroughly  dried 
cast  (mask)  with  separating  fluid  and  pouring  into  it  plaster  of  Paris 
until  it  is  thoroughly  filled.  This  is  now  allowed  to  li&rden  and  di'v, 
when  the  mask  is  carefully  picked  off  from  the  positive  at  the  i)ink 
line  of  demarcation  of  the  fluid.  The  chips  and  defects  on  the  positive 
cast,  caused  by  this  tedious  process  of  picking  off"  the  mask,  must  be 
repaired  with  plaster. 

Secondary  casts  and  photographs,  showing  the  eff'eet  of  treat- 
ment, are  of  service  as  additional  records,  while  stereoscopic  photo- 
graphs are  even  better  than  plaster  casts. 

Rhinoplasty. 

Classification  of  Nasal  Deformities. 
I.     According  to  Roe  : 


Hoiiy   j'Oiticni 


portion 


Convex     Ouncavo     SiiatuUiteJ     Deflected 


Tip 


Willis 


Collapseil        Expaiidea 


lOx.-essive 
(leliciciit   tissvie 


Deflection    from 
median  line 


n.ASTic  sn;(iKi;Y  ok  tiik  nosk  anh  kai;. 


2Si> 


rr.      AccuKMNi;    1,1   Kill. IK.      (Ill  ilftici.'iirics  ]..i rt Iciiliirly   rt-ri-ralilt' 
tn  p.-iralliii  iujcctiiiiis. ) 


1.     AnU'i-ior  Xasal  |)i'lic''n'iii'V 


Superior  one  l liiiil. 
Middle  oiu'-tliinl. 
liifcrior  oiu'-tliinl. 
Superior  ono-Iialf. 
Inferior  one-half. 
Total. 


Total 

2.  Lateral  Insunicieiicy 

3.  Lolmlar  Iiisul'iicieney. 

4.  Iiiterlnliulai-  lii^iirru'iency. 
.").     Alar  I  )i'rn-ii'iicv 


)  I'liilateral. 
I  P,i lateral. 


riiilatoral. 
r.ilateral. 


Ck     SiiKM.iilal    hcli.-ieiK'V 


)  i'artial. 
( Complete. 


111.     -Vutlior'.s  (.'lassilicnlinii. 

A.  Eliulogy. — Traumatic,  Luetic;  t'oiiiivuital ;  Tubercular  and  Lu- 
pus; Simple  infectious,  as  abscess;  i\n-iclioiulritic;  Atheromatous,  or 
Acne  Rosacea:  Xeojilasiiis,  ninliii'iiaiit  and  lieiiiuii:  (Iross  liiiai;"inati()n. 
(ii-  \'auity. 

Ii.  Funii. 

1.  Larue  liunip  nose. 

2.  Twisted  nose. 

.'..  Kinked  and  doiilili'  kinked. 

4.  Sa(ldlel)aek.  kinked  and   witli   wide  alu'. 

■").  i*iu(^iK'd  pointiMl,  \\iili  c'dllap-ed  ahe. 

(J.  Flat  or  squasheil,  witli  lar.ne  ak-e  and   lai',L;i'  xcstilinles. 

7.  Xotchcfl. 

8.  ("ou.^'enital  aiisenee  u\'  |ii-eiiia\illa  am!  cnlniiieliar  cartila.n'o. 

9.  Pushcd-in  nose. 

10.  .\bseuce  of  external  nose  and  septum. 

11.  Unilateral  defunnities. 

12.  Hare  lip  nose. 

l-'k      ( '(niiliinalioii   of  nasal   and    fa'^e   dermiiiit  ics. 
14.      I'nmiij  III-  liyperl  nipjiir  nose. 


290  OPEItATlVE   SURGERY   OF   THE   NOSE,   THROAT,   AXI)   EAR. 

Methods  of  Procedures  in  Nasal  Deformities  and  Malformations.^ 

T.  Gonnan  or  French  method,  iiichuliny  skin  <;raftin,i4'. 

TI.  Italian  or  Ta.si'liaeozzi's  nictlind,  witli  niodiiications. 

HI.  llinihto  or  Tmlian  method. 

IV.  l)oid)h'  transi)hintation  method  (toe  to  hand,  to  nose). 

y.  Finder  method. 

\'T.  ( 'lavicde  metliod. 

A'ir.  Tm])]antati()n  method  (parathn,  etc.). 

A'lII.  Reduction  method. 

IX.  Artificial  method. 

X.  Ortho})edic  method  (Carter's  clamp,  i)ins,  etc.). 

XI.  Intranasal  method. 

XII.  Miscellaneous  and  combination  methods. 

I.    German  or  French  Method.     (Facial.) 

When  a  subtotal  destruction  or  an  unilateral  defect  is  to  be  cor- 
rected this  method  gives  excellent  results.  The  transposition  of  the 
newly-formed  parts  may  be  accomplished  by  sliding  or  pedicle  forma- 
tion. Small  defects  may  be  covered  by  rearranging  flaps  from  the 
nose  itself  as  shown  in  Figs.  234  and  235. 

The  nasolabial  fold  offers  the  best  place  for  pedicle  flaps.  Flaps 
for  building  up  the  jironunence  of  a  nose  as  well  as  for  forming  an  epi- 
dermal lining  of  the  nose  are  frequently  formed  from  the  cheeks  and 
turned  outside  in,  as  shown  in  Figs.  228  and  229.  Columellse  may  be 
made  from  the  point  of  the  nose,  from  the  outer  part  of  the  middle  of 
the  lip,  or  from  the  mucous  membrane  of  the  lips,  and  passed  through 
in  buttonhole  fashion,  as  shown  in  Figs.  252-2(50.  It  is  most  im])or- 
tant  to  loosen  the  parts  thoroughly  and  to  effect  perfect  adaptation 
of  the  margins.  Portions  of  the  nasal  bones,  nasal  processes  of  the 
superior  maxilla  or  of  the  premaxilla  and  the  floor  of  the  nose,  are 
utilized  for  support  of  the  nose  formed  after  this  method.  (Figs.  286 
:and  287.)  Other  materials  for  support  are  cartilage  from  the  septum 
resected  from  other  jaatients,  or,  clavicle,  and  bones  from  the  toes, 
Angers,  and  the  anterior  surface  of  the  tibia.     (Figs.  307-314.) 


IM.ASTIC    SIIICKIIV    or    TIIK    NdSK    ANH    KM!. 


2f)l 


C'UHRKCTKIN    111     r  Ml.Al'l'.l!  \I.   A  Nil    PaIIIIAI.    I  )|.I  ICI  K.NCI  I'.S  (IK  TIIK    XdSK. 

Legg's  Operation. 

1.       .M:ikc   ;i   sili.-lll    Idlimii'  sIi;i|mmI    |1;||i.   with    il-   lliimv   |irilirli'   .'it    tllC 

iiiisohibial  .-ivaso.     (Fii;-.  lil'S.) 

-.  Tiini  ovor  witli  skin  surl'aiH'  iiitu  llic  \  fsliliiilc.  .iml  .-uliiii'  all 
aliout  tlio  niarit'ins  ol"  tlio  ala.  wiiicii  have  licon  rrt'siiciicii  u|i.  aihl  close 
<'ivatod  di't'wt  on  tlio  cliook.     (  Fii!.  i'l'!>.) 


Fig.  228.  FiS.  229. 

Lefis's  (iperatidii   for  poirection   of  unilateral   and   pr.itial   dcru-icncics  oi:   (he   nose. 

(hn    WrrI:  Lahr. 

•'1.     Sl'vit  the  iiodicio  aiiil   irmljust,  lln'ii  siilurc  to  ihc  ri'inainiii.n 
.liar  iiiaru:ins. 

-!.     t  n\i'i-  the  llap  Willi  a  tliin  TliiiMsrli   i^raft. 

Koenig's  Operation. 

1.  Make  ;i  >iMiiiliinar  iiH-isiiiii  tiiinimli  llic  ala  rrniainiii,ii'  and  dis- 
soct  the  niariiiii  away.     (  l-'in.  I'.'lu. ) 

2.  Take  a  Wolfe   -i-ari    iVuin   ihc  ihick   skin   nf  the  hack  of  the 
nrck  and   iiiiiilant  into  the  alar  drfcct.   I  l-'i.n'.  'I'M.) 

Von  Esmarch's  Operation. 

1.     ]\rake  a  tlap  in  lii..  n.-i-uh-ihial  Inhl.     i  Ki.i;-.  'i:!--!.) 
-.     'rnni  nil  ii>  |irilicic  with  the  skin  outwards  and  snlnre.     {V'wx. 
•2Xi.) 

'.').     Mveiit  iiaii\  >c\cr  till'  |icdicli'  nnc  week  later  and  readjust  jiarts. 


202  OPEKATIVE    SURGEHY    OK    THE    XOSE,    THUOAT,    AND   EAR. 


Fij;.   2-M.  Fig.   281. 

Koenig's  operation. 


Fig.  2:^2  Fig.  2 

^'ou   Ks^iuaic-h 's  operation. 


Pig.  234. 


Fig.  23.5. 


Von   Liuigenbock's   operation. 


ri.AS'i'ic  sri;(;i:i;\    m     iiii.   nosk  and  i;ai!. 


293 


Von  Langenbeck's  Operation. 

1.      Frcslii'ii  up  till'  surfarcs  on  llic  dcrrc-t. 

-.  MaUc  a  flap  on  tlic  lioaltliy  siilr  «\'  tlic  imsr  with  llic  prdidc  over 
the  sid.'  of  tlio  (li'tVct.      (Fii--.  •2:U.) 

.'!.  Pi-SL'ct  this  flap  loose  and  stitrh  inlo  ihc  pivjiaivd  dciVct, 
luiiiiii^  ill  the  lowiT  niariiin  of  tlu'  Ha]i  so  as  to  make  tiio  nosfril  have 
a  dciinal  snrfaco.     (V'liX.  '2'.\').) 

4.  Covor  llio  nowly-foniird  delect  eillicr  with  si<in  graft  or  dis- 
sect loose  the  tissne  of  the  eheeks  and  eovei-  the  defeet  l)y  slidiiiii'  tlie 
skin  over  it. 


Fig.   2.36.  Pig.    237. 

T')iefTfiil.:ii-li  's  oponition. 


Fig.    2.SS. 
Voii  Ksmarcli  "s  opciatioii. 


Dieffenbach's  Operation. 

1.      .Make  a  i-e\eised   \'-sliap<'d  ineisioii  tlii-niiLih  till'  nia  almxe  the 

defeet    ;ind    dis-eet    free|\  .       (  fii;'.    -^'M'}.} 

-■       li'eUllite   ill    the    foMIl   of   t  h  ri'e   t  liree-eorilered    tlajiS.       {V\iX.   '2'.]~ .) 

Von  Esmarch's  Operation. 

1.       l''reshell    lip   the   niarii-iiis   of  the   defeel. 

L'.       Make  a  flap  of  the  si.h'  .,f  the  el:e,-k   willl  :i  pediele  on  tile  side  of 

the  no.se.     (Fi.u;.  '2'.'i^.) 

3.  Implant  llap  ami  Mitnie  on  tiiree  sides. 
Oin-   lI'rrA-  Later. 

4.  Sever  the  pedicle  and  eonipjete  the  eh)sure  uf  the  defect  on 
tile  ala  as  well  a.s  of  tiie  new  ly  formed  defect  on  the  side  of  the  nose  and 
<-iieek.     (Fig.  238.) 


294 


ormtATivE  st"i;(;ki;v  of  tttf,  xosk,  TirnoAX.  anh  eai;. 


Busch's  Operation  for  Partial  Loss  of  Tip  and  One  Side  of  the  Nose. 

1.  Foi-ia  a  lateral  flap.  The  pcilidc  is  fovmod  on  the  side  of  the 
elieek  oiiiiosite  to  the  defect  of  the  ala,  ;uid  tlie  main  liody  of  the  flap 
is  made  from  the  bridge  of  the  nose.     (Fiy.  --ill.) 

2.  Eemove  the  undesirable  skin  margin  of  defect. 

o.  Dissect  the  flap  and  suture  in  position,  the  prominent  convex 
border  of  the  flap  being  fitted  well  into  outer  margin  of  the  defect. 
The  tongue-shaped  poi'tion  makes  a  well-adjusted  tip  and  cohimellfe 
covering. 

4.  Tiie  newly-formed  defect  is  covered  and  corrected  one  or  two 
weeks  later,  when  tlie  iiedicle  is  severed. 


Fig.   ^'MK 
Busch's  oiiciutioii  for  partial  loss  iif  tip  and  oiu'  side  of  nose. 


Nelaton's  Operation. 

1.  Form  two  quadrangidar  flaps  from  the  cheeks,  the  bases  of 
which  are  situated  over  the  bridge  of  the  nose  and  angle  of  the  eye. 
One  of  the  flaps  should  have  an  additional  central  flap  to  form  the 
columella.     (Fig.  240.) 

2.  I^reshen  the  margins  of  the  defect. 

3.  Bring  flaps  together  and  suture  in  place  over  the  filtrum  of 
tlie  columella. 

4.  Cover  created  defect  either  by  AVolfe  or  Thiersch  grafts,  or 
slide  over  the  skin  from  the  cheeks. 


vi.A^^Tir  srncKKY  ok  thk  xosk  and  km;. 


2'X> 


Syme's  Operation. 

1.  'I'wd    l;ilri;il    Maps   arc   iiiadr.   niic   to  each    -iilc   of   llio  defect, 

cxtciuliu.i;-  to  tlic   lateral    puiti if  llic   luisc   ami    \n   \\\r  clicok.s,   botll 

tlu'se  Haps  liaviiii;'  a  c<iiiiiii<iii  central  |icilicle  nver  the  indi  nf  tlic  iio.se. 
(Fi-   2-il.) 

2.  Freshen  up  the  niarL;iii>  dl'  the  nasal  ili'lVcl. 

."..     Sntnre  the  two  Haps  loucthei-  in  the  nie<llan   line. 

4.     Turn  the  skin  in  at   the  luwcr  niar,L;ins  ol'  the  llap,  ami  sutnre 


Fig.  240. 
NOlaton's   operation. 

so  as  to  make  a  cutaneous  suiTace  where  tlie  uostrils  will  sul)sc(|uenfl\' 
be  fonned.     (Fitr.  241^.) 

5.  Suture  the  twii  lateral  Haps  into  the  raw  sni'l'ac-i'  on  the  side 
of  the  nose. 

'i.  Dissect  the  >kin  ,,r  the  check  ami  hriii-  it  close  to  the  lateral 
tiaps  and  suture.  Any  defect  rcniainin.t;-  may  he  eo\ercd  liy  skin  g'rafts 
or  he  allowed  to  granulate. 

7.  Tubes  of  stiff  rublier  are  ))!aced  iu  each  in-imitive  nostril. 

8.  Subsequent  rurniatitm  nl'  the  cuhiiiiclla  iVuin  the  upper  lip. 

CoiiKiccTKi.v  or  TdiAi,  Loss. 

Helferich's  Operation  (Frencb  Method). 

I.  .Make  a  i|ua(_lranj;ular  llap  iVdin  (Hic  >idc  n!'  the  cheek  with  its 
liedicle  on  the  side  of  the  nose,  for  the  imrpuse  n\'  support  and  to  line 
the  nose  with  skin.     (Fig.  '24:^>.) 


20G 


OPKKATIVK   SnuiERY   OF   THE   XOSE,   THROAT,   AND   EAR. 


Fig.  2J2. 
S\nnc's  operation. 


PIASTIC   Sl'KGKKY   OF   Tllli    NOSK    AXP    EAR. 


297 


/r- 


Fig.  243. 


^ 


Fig.  244. 
Helferich's  operation  for  total  loss  of  nose. 


298  OI'KltATIVE    sriKIKIIV    OF    TTTK    XOSE,    THROAT,    AND   EAK. 

2.  ?il;il<('  a  sdiiicwhat  obloiit;-  Haji  rnmi  llic  ntlicr  clicck  with  its 
])e(iiclt'  jihu-cil  towards  tlic  inner  rorncr  of  tlic  eye,  for  tiic  inir|)ose  of' 
covering  llic  first  fiaii,  and  reconstruct  the  nose.     (Fig.  24."!.) 

3.  Dissect  and  turn  the  quadrangular  fiap  across  tlie  naval  ih'fcct, 
and  suture  the  previously  freshened  margins  of  the  nasal  defect,  facing 
its  skin  surface  into  nasal  cavity.     (Fig.  244.) 

4.  Dissect  oblong  Hai»  and  bring  it  in  contact  with  tlie  denuded 
surface  of  the  first  flap,  and  suture  in  i)lace. 

5.  Close,  by  sliding  and  ieadaj)ting  the  skin  al)()nt  the  cheeks 
over  the  newly-formed  defects. 

One  Week  Later. 

G.  Sever  pedicles  and  readajit  the  ]iarts  to  a  smoother  healing 
surface;  secondary  (i]»eration  upon  the  aliv  and  columella. 

Roberts'  Operation  for  Sunken  Bridge  With  Upturned  Lobule  or  Tip 
of  Nose.    Fi(!.  24."). 

1.  A  transverse  incision  is  made  into  the  nasal  cavity,  the  tip  of 
the  nose  being  ])ulled  down  so  that  the  nostrils  ap])ear  horizontal. 
(Fig.  246.) 

2.  An  inverted  V-shaped  incision  is  made  between  the  eyes  up  to 
the  forehead.     (Fig.  246.) 

3.  The  skin  ancj  subcutaneous  tissue  l)etween  tlie  first  transverse 
and  the  second  V  incision  are  dissected  thoroughly. 

4.  This  dissected  skin  is  brought  down,  the  ]»oint  of  the  Haj)  dis- 
placed as  low  as  possible,  and  the  lower  defect  broadly  sutured.  (Fig. 
247.)  This  fonns  a  good  prominence  over  the  fonner  depression. 
Dressing  should  be  retentive  so  far  as  to  hold  the  tip  of  the  nose  down. 

Roberts'  Operation  for  Sunken  Saddle-back  Nose. 

1.  Sever  the  lobule  and  ahv  from  their  bony  and  cartilaginous 
attachments  at  the  deepest  ])art  of  the  saddle. 

2.  Draw  the  lobi;le  and  al;v  down  so  as  to  Ining  the  nostrils  into 
an  almost  horizontal  plane;  this  leaves  a  conical  defect  into  the  nasal 
cavity.     (Fig.  248.) 

3.  Make  two  small  skin  flaps  from  the  cheeks  with  their  ])edicle 
towards  the  root  of  the  nose.     (Fig.  248.) 

4.  When  these  flaps  are  dissected,  they  are  turned  with  their  e]n- 
dermal  surfaces  toM^ards  the  nasal  cavity  and  are  miited  one  to  the 
other  as  well  as  to  the  upper  portion  of  the  newly-formetl  defect  in 
the  nose.  This  brings  their  raw  surfaces  externally  for  granulation 
formation  and   subsequent   sui)i)ort  for  the  newly-formed   skin   flaps. 


PLASTIC    SURliKltY    OF    TIIK    NOSE    AND    EAR. 


2!)f) 


Fig.  2-1.- 


Fig.  246.  Fig.   247. 

Robert's  oppriilidii   for  sunken   bridjic  with   upturned   lobule  or  tip  of   nose. 


300  OPEKATIVE   SUKGERY   OF   TJIE   NOSE,   THROAT,   AND   EA 


Fig.  248. 


Fig.   249. 


Fig.  250.  ■  Fig.   2.51. 

Robert 's   operation   for   sunlcen   saddlobaok   nose. 


PLASTIC    sritdKItY    OF    TIIK    XOSK    AND    KAI!.  301 

'riic  (U-rt'i-ts  in  tlu"  I'lu'oUs  iTcjitc.l  li\  tli.'sc  ll;i|.s  ••nc  at  mic-.'  united. 
(Fig.  249.) 

5.  About  one  wct'k  to  ten  days  lat.T.  the  irregularities  aliniit  the 
base  of  tlieso  ehoek  llaps  are  eiuiceted  liy  iuci>itins  and  |iro|ier  sutures 
so  as  to  olilain  n  sninntli  surface. 

(i.  When  all  the  inllaiiiiiialnry  ivaeiinii  lias  disajipearod,  usually 
in  about  three  to  lour  weeks,  an  inverted  \  -sliaped  ineisiou  is  made 
down  to  the  bone.  Correspoiulin^  to  this  ineisiou  .just  al)ove  the  margin 
of  the  nasal  defect,  which  is  now  covered  by  the  iuvertetl  skin  flaps,  a 
similar  ineisiou  is  made  excejit  that  the  leirs  of  the  V  run  more  hori- 
zontally. AVhile  \\n'  k-i-s  of  the  npiier  ineisinu  Irniiinale  below  the 
eyes,  close  to  tiie  inner  corner.  \\\r  lnu  ei-  eouie  nut  lint  lirr  on  t  he  cheeks, 
.iiiviug  greater  plasticity  td  tlir  lla|i>.  The  ajiiees  nl'  the  two  in\'ei-ted 
\'-shaped  ineisiiuis  are  now  joined  liy  a  vertical  one  iiinncilialely  over 
the  crest  of  the  nose.     (Fig.  250.) 

7.  Those  two  flaps,  rhomboid  in  form,  are  dissected  very  freely 
from  the  underlying  tissues  and  the  cicatrized  surface  of  the  skin  flaps 
covering  the  defect  freshened  by  gently  scraping  with  the  knife  blade. 
One  flap  is  turned  so  as  to  fit  its  extreme  point  or  tiji  into  the  opposite 
extreme  point  of  tlii>  defect  and  is  anchored  li>  a  suture:  tlim  the  sec- 
ond flap  is  brought  above  llie  lirst  so  as  to  till  in  tiie  defect  to  i  he  great- 
est extent,  and  is  anchored.  This  will  leave  a  somewhat  triangular 
defect  at  the  root  of  tlio  nose  and  lower  portion  of  tiie  forehead  which 
is  closed  by  three  or  nioic  sutures  in  a  \-ertical  line.  The  two  flaps  are 
noAV  sutureil  to  the  \arious  nuirgins  and  to  themselves  as  sliown  in 
Fig.  251. 

FoliMATIOX    (IF    A    XeW    ( 'oLT-M  EI.I.A    (Fko.M    TliK    I'n'Ki;    Ijl'). 

Dieflfenbach's  Operation. 

1.  Two  ]iarallel  ineision>,  sei)arated  about  one  foiuili  inch,  are 
made  through  tin-  entire  thickness  of  the  upiicr  lip  up  to  the  margin 
of  the  nasal  floor.     (Fig.  252.) 

2.  Turn  this  tongue-shaped  llap  >o  thai  the  skin  surface  looks 
into  the  nasal  cavity  and  nincons  incinhrane  externally,  and  locate  a 
lioint  wiiere  the  free  end  of  this  llap  will  toueii  the  nasal  tip  without 
undue  tension  or  twist  of  tiie  iiase  of  the  llap. 

.'J.     Denude  this  located  area  of  skin.     (  Vlu:.  252.) 

4.  Remove  the  mucous  membiaiie  from  the  tip  of  the  t<uigue- 
shapcd  flap. 

5.  Suture  this  liji  into  denuded  surface  of  nasal  tip.     (Fig.  253.) 
li.      I.ilierate  the  tnai'^ins   of  ijii'   ni'W  ly-forniec]   defect    in   ihe  mid- 
dle   of    the    lip. 


302 


OPKUATIVE   SURGHUY   OF   TITE   NOSE,   THROAT,   AND   EAE. 


7.  Siitiiro  skill  and  mucous  monibi-ane  soparatoly.     (Fig.  253.) 

8.  If  the  operation  is  on  a  man,  it  may  be  necessary  to  denude  the 
ton£>-ue-shai)ed  flap  of  its  dermal  covering  as  the  hair  wouhl  suhse- 
(piently  irritate  the  interior  of  tlie  nose. 


Fig.  252.  Fig.  253. 

I)ieff'i.'nli;ich's   iiporatioii   t'cir   fiirmation   of  new   c-dUiniella    from   the   uyiper  )i[). 


% 

^ 


•^2::^- 


Operation  for  forniatioii   of   new  colunicllu  from  tlie   dorsum   of   the   nose. 
(Hindoo  method.) 


yrom  the  Dorsum  of  the  Nose  (Hindoo  Method). 

1.  An  oblong  flap  is  made,  the  pedicle  being  at  the  side  of  the  ala 
running  to  the  tip  of  the  nose. 

2.  A  defect  is  made  at  the  jnncti(ni  of  tlic  upper  lip  with  Hoor  of 
the  nose.     (Fig.  254.) 


ri.A.-ric  sriiGF.nv  or  tiif.  xosk  and  ear. 


■M) 


;i     Till'    ll.-i)!    i-    luninl    iliiu  iiu  ;inl    ;inil    sutured    into   this    dcrcct. 
(  Fisr.  25").) 

4.     The   (Irfi'ct    (111    (liiis\iiii    111'   iinsf   is   siiliircd   or  ;i   skill    uT.-it't    is 

lls,.d. 

.").     Any  sli,«:lit   irri\n'iil;iritii's  mc  \i<  \>r  cdni'ctrd  at   a   siilisi'i|ii('iit 
tiiiif  wlioii  tlio  jx'diflt'  is  severed. 


Vv,^ 


,01111  III 


FiR.  259.  Fij;.  ;;(i(i. 

Lexer's  operation  for  tin-   formation   of  coluniella    from   tlio   mucous   nu-ni- 
loanc  of  tlio  up|u'i'  lip. 

Lexer's  Operation  for  the  Formation  of  Columella  (from  the  Mucous 
Membrane  of  the  Upper  Lip). 

1.  Cniistnict  a  toiiii'ue-sliaped  llap  with  its  hase  towards  tiie 
lofiiiuival  iiiaruiii  on  the  under  snrfaci'  u\'  ihe  u|iiiei-  lip.  made  up  of 
inucou.s  iiK'iuhram'  and  smiie  uiKh'ilyiiii;  suhniucdiis  tissue.     (Fi.ii'.  '27A).) 

2.  Disisc'ot  it  loose,  and  eldse  to  its  liase  remove  tin  oiiithelial 
surface  of  a  small  transverse  snip  whirh  will  snlise(|iiently  he  witliin 
a  huttonliole  of  the  upper  lip.      i  l-'iu.  L'.'iT. ) 

."!.  Form  the  fhip  in  a  soit  of  a  nil!,  siitiiriim-  tin'  iiiaryins.  (Fie:. 
258.) 


304  OPERATIVE   SURGERY   OF  THE   NOSE,   THROAT,   AXD   EAR. 


Fig.  261. 


Fig.  262. 
Italian  or  Tagliacozzi's  method. 


ri.ASTu-  siT.cKnv  or  tiik  xosi:  and  kah.  305 

4.  .Makr  a  luiKoiiluiK'  in  tin-  n-iitiT  al  tlio  jiiiu-tidii  nl'  tlic  u|i|ut 
li|i  ami  Hour  of  tlie  nose,  throujjh  tlio  thii-Unt'ss  of  tlio  lip,  in  rront  nl" 
the  iH'dirlc  (.!'  tli.'  tlap.  (  Fi.ii'.  'J.');).)  Also  iiiak.-  a  iiulcli  at  (lie  tip  of 
the  nosi'. 

5.  Bring  tlio  Map  throuuli  aiul  suture  into  tlit-  notch  at  the  tip  of 
the  nose  and  also  at  the  bnttonholo.     (Fig.  260.) 


Fig.  263. 
Italian  01-  Tngliacozzi's  method. 


II.    Italian  or  Tagliacozzi's  Method. 

This  nictlioil,  w  hicli  is  the  oldest,  is  not  einployetl  to  any  groat  ex- 
tent at  the  present  time,  as  the  patient  is  verj'  nineh  inconvenienced  by 
having  his  arm  held  in  a  very  constrained  position   for  such  a  long 


nnCi  Ol'ERATIVK   srR(iKi;V   OF   THE   NOSE,   THROAT,   AND   EAR. 

pci'iod.     Tls  ]iiii']K)si'  is  to  olitaiii  ;i  f1a|i  IVuni  llic  ai-iii  as  shown  in  Fi.n'. 
•-'(11. 

1.  'I'lic  fla])  may  be  allowed  to  l)ecoine  iinti  and  of  ])roper  size  l)y 
jihu-ini;'  niliber  tissue,  Cargile  meinbrane  or  anointed  .nai^i^'^e  between 
the  deimded  surface  so  as  to  pre\('nt  it  from  reuniting'.  The  flap  should 
always  be  made  one-third  larger  than  the  surface  to  be  covered  on 
account  of  the  subsequent  shrinking. 

2.  After  the  parts  about  the  nose  are  freshened  and  loosened  ui) 
the  tla])  is  sutured  for  about  two-thirds  of  the  distance,  holding  the 
liand  over  the  top  of  the  head  and  fixing  it  by  means  of  adhesive  plas- 
ter as  in  Fig.  262.    The  jjedicle  should  not  be  twisted  too  acutely. 

3.  A  complete  immobilization  plaster  cast  is  put  over  this  jui- 
mary  adhesive  fixation,  care  being  taken  to  protect  the  eyes  whih/  it 
is  being  applied.  After  it  has  thoroughly  hardened,  spaces  or  win- 
dows are  cut  out  so  as  to  ex])ose  the  Avouml,  the  eyes,  ears  and  mouth, 
as  in  P"'ig.  263.  The  wound  is  eovei'cd  by  a  separate  dressing.  This 
cast  is  allowed  to  remain  until  the  parts  have  healed,  the  stitches 
being  removed  usually  in  one  week  to  ten  days.  It  is  then  time  to  sever 
the  attachment  of  pedicle  to  the  ann.  The  remaining  portion  of  the 
defect  about  the  nose  is  freshened  and  loosened  up,  the  ])edicle  trimmed 
to  fit  the  pai'ts,  making  allowance  for  a  columella,  and  the  external 
parts  of  the  nose  finished.  The  skin  defect  on  the  ai'm  is  cleansed, 
the  margins  are  freshened  and  loosened  u]>  and  sntnrt'd.  ({rafts  may 
be  used,  or  tlie  defect  may  be  aUowed  to  heal  1)y  granulation. 

Israel's  Operation. 

Instead  of  olitaining  tlie  tla]i  from  tlie  arm,  one  is  made-  from  the 
forearm,  and  the  arm  and  forearm  are  so  placed  as  to  make  the  patient 
most  comfortable,  as  shown  in  Fig.  26-1.  The  retention  of  the  arm  is 
tlie  same  as  in  the  Tagliacozzi  method. 

1.  Make  incision  in  left  forearm  synnnetrically  on  l)oth  sides  of 
the  ulnar  edge,  and  form  a  trapezoidal  skin  flap.  The  small  part  of  the 
trapezoid  Avhich  points  towards  the  wrist  should  be  4.5  cm.  from  the 
styloid  process.     (Fig.  265.) 

2.  With  a  chisel,  outline  a  bone  flap  from  the  ulna  in  connection 
with  the  x^artially  dissected  skin  flap  0.75  cm.  wide  and  6  em.  long. 
(Fig.  265.) 

3.  With  a  fine  saw  this  bone  sliver  is  severed  from  the  uhia,  care 
being  taken  that  it  remains  attached  to  the  skin  flai)  and  to  the  ulna 
at  the  upper  end.     Iodoform  gauze  is  interi)osed  to  prevent  reunion. 

A  Few  Days  Later. 

4.  Break  the  lione  bridge  at  the  point  where  the  tip  of  the  nose  is 


rr.ASxrc  srnoKRY  or  tuk  xosk  axd  f.ah. 


307 


Id  lit'  t'(iinu'<l  Mini  <lri'ss  in  this  t'nnn.     Allow  for  .irciitri-  lliickcuiim-  of 
I>;irts  for  aiiollu'r  tlirce  Id  li'iir  i\:\}>. 

5.     Tninsiilaiil  Hap  to  nasal  tk'tVct  ami  lix  at  tlie  side  as  shown 
in  Fiy.  l2(i4.   Innnohilizo  by  tlii'  usual  nu'thod  of  plaster  of  Paris  jaekut. 


'lira  Weeks  Later. 

G.  Sever  the  Imny  and  skin  pcdirlc^  and  fradju^l  p;irt>  to  I'drni  a 
nose.  The  hone  should  lie  iniili'd  with  ilir  nasal  spiiu'  at  the  tlnnr  of 
the  nose  and  the  skin  >nlnicd  aliout   thr  >idi'  of  the  nose. 

7.  Form  the  colnincjla  anil  nostril  from  the  icniainini:  skin  tlap 
that    was  iMirposcly   tnki'ii    lni-   tlirir   formation. 


30S 


OPERATIVE   SinuiERY   OF   THE   NOSE,   THROAT,   AXD   EAK. 


Dieffenbach's  Operation. 

1.  ()iitliiie  a  train'X.oidal  Hap  above  the  elbow  on  the  inner  sur- 
face, one-third  larger  than  the  newly-formed  nose  is  to  be. 

2.  The  heavy  lines  in  Fig.  266  show  the  formation  of  incisions 
and  this  skin  flap  is  dissected  freely. 

3.  Tnrn  in  one-half  of  this  flap  so  as  to  bring  tlie  skin  next  to  the 


Fig.    266.  Fig.   267. 

Dieffenbach's  operation. 


Fisr.    268. 


raw  surface  of  the  arm  in  order  to  prevent  adhesion  and  also  to  fonn 
the  so-called  roll  of  the  dorsum  of  the  future  nose;  fasten  by  two 
sutures.     (Fig.  267.) 

Six  Weeks  Later. 

4.  Sever  the  upper  part  of  tlie  flap  and  turn  downward.    Eemove 
the  two  stitches  and  lay  the  flap  open  partially.     (Fig.  268.) 

5.  Freshen  up  margins  of  the  nasal  defect  and  suture  in  this  new 
flap  as  in  the  usual  Italian  method. 


PLASTIC    SfnCKIlV    ni-    TIIK    \OSK.    AXU    F-AH. 


309 


run  Weeks  Ldfii. 

(i.     Sever  tlic  inMlirlc  ;iiul  readjust  the  jiarls  to  rmiii  the  nliv  ainl 
eoluiiii'lla. 

Nekton's  Operation. 

1.      I'"iinii  a  iii'ilicli'  lla|i  rrmii  llir  rorcaiiii  and  attacli  t<>  tlii'  mar- 
gins of  the  .h'ffct.     (Kig.  •2i\[).) 


Fig.  269. 


N<51.Tton's  operation. 

Tna  Wcck.^  Later. 

2.  Sever  the  pedicle. 

3.  Fonn  two  flaps  from  the  oiitfr  inaiLiiii  nl'  the  alar  niiciiin.us 
outwai'd  and  downward  as  low  as  the  inriiinr  iiia\illa  in  llic  naso- 
labial fol.l.     (Fig.  270.) 


310 


OPKUATIVE   SV'RCKnV   OF   THE   JTOSK,   TTIKOAT,   AND   EAR. 


4.  Turn  tlicse  so  as  to  make  skiii-liiicd  nostrils  and  also  a  coln- 
luclla  ni-  septum  support  for  tlu'  new  fm-mcil  tlap,  whicb.  should  also 
iuchidc  a   small  flap  for  tlu'  formalioii   nf  a    double  ooluniella.      (  l''i^. 

.1.     Suture  these  flaps  to  one  another  and  close  the  defect  in  the 
nasolahial  fold.     (Fig.  271.) 
Tiro  Wecl<s  Lafcr. 

(!.  Sever  the  pedicles  of  the  two  fla))s  and  adjust  them  to  ilie  aia' 
of  the  nose.    Also  reconstruct  the  eolumella. 


III.     HINDOO  OR  INDIAN  METHOD. 

This  is  hv  far  the  ]ireferal)le  method  when  there  is  so  much  de- 
struction of  the  nose  that  insuflicient  tissue  is  obtainable  in  the  imme- 
diate neighborhood,  as  the  cheeks  or  the  nose  itself.  The  tlai)s  may 
varj'  as  to  their  shape  and  outline,  according  to  the  area  to  be  cov- 
ered and  according  to  the  area  of  the  alae  or  upper  portion  of  the  nose 
that  is  present  or  can  be  utilized.     (Fig.  272.) 

The  character  and  extent  of  the  defect  determine  the  side  of  the 
forehead  from  Avhich  the  flaps  are  to  be  made.  In  this  particular,  the 
flaps  should  be  so  constructed  that  the  pedicle  should  contain  the  angu- 
lar artery,  which  should  be  subjected  to  very  little  twisting.  In  fact 
no  tension  must  be  exerted  anywhere  on  these  flaps.     The  flai)s  may 


n.Asiii'  sri:i;i:uv  ov  tiik  xosk  anh  i;ai:. 


:!11 


\>v  ruriiR'cl  of  llif  skill  and  part  nl'  its  iiinlcrlx  iiiL;'  i-iniiH'c-tivi'  tissue  only, 
or  tlioy  may  contain  the  ]icriostcuni  ami  even  a  portion  of  tlic  cxtiTiial 
tal)k>  of  till'  frontal  l>on.'.    The  frontal  .Id'eets  thus  createil  liy  the  turn 
iu<;-  of  the  Haji  ina>    he  eoxcred  in  several  ways.     I^y  loost'iiini;  up  the 


I'iiT.    :J7L'. 
Jliiidoo    or    liiiliaii    iiicthint    of    ll;i|i    formation. 


Fi-.  ■27:;. 


niicTscirs  oi.r.rali 


312  (lI'EliATIVIi   srK(;KllV   OF   THE   NOSE,   THROAT,   AND   EAR. 

margins  and  di'awing  the  parts  together  as  far  as  possible,  the  granu- 
lation may  be  encouraged;  a  Thiersch  skin  graft  may  be  used,  or  the 
entire  area  may  be  covered  by  skin  graft  (Thiersch,  Wolfe  or  Kraiise). 
After  union  takes  place  the  pedicle  is  severed  and  the  stitches  are 
removed.  It  requires  usually  about  eight  to  ton  days  before  the  pedicle 
is  cut  off,  and  it  is  frequently  very  thick  and  large,  so  that  it  must 
be  trimmed  off  and  adjusted  to  the  still  existing  defect  between  the 
eyebrows  and  root  of  the  nose. 

Thiersch's  Operation  for  Total  Loss  of  Nose. 

1.  ]\rake  two  small  quadrangular  fiaj^s  from  the  cheeks  at  the 
lower  portion,  forming  their  hinge  at  the  side  of  the  nose  where  they 
will  constitute  the  inner  sui"face  of  the  nostrils  and  ala  of  the  nose. 
(Fig.  273.) 

2.  Dissect  them  loose  and  turn  them  with  their  dermal  layer 
towards  the  nasal  cavity. 

3.  Suture  one  to  the  other  in  the  median  line. 

4.  Make  a  frontal  pedicle  flap  and  suture  into  the  freshly  denuded 
margins  on  the  side  and  loAver  part  of  the  nose    (Fig.  273.) 

5.  Cover  newly-formed  defects  by  Thiersch  grafts. 

Nelaton's  Operation  for  Total  Loss  of  Nose  (Indian  Method). 

1.  Expose  entire  length  of  costal  cartilage  of  the  eighth  rib. 

2.  Excise. 

3.  Trim  down  to  a  size  2.5  cm.  long  by  3  mm.  wide. 

4.  Cut  a  notch  where  the  point  of  the  nose  is  to  be  formed  by  this 
cartilage,  that  is,  about  0.75  cm.  from  the  end  nearest  to  the  base  of 
tlie  forehead  pedicle. 

5.  Outline  the  forehead  flap. 

6.  Incise  the  base  of  this  flap  down  the  bone  for  about  0.5  cm.  and 
make  a  tunnel  to  fit  the  cartilage  strip. 

7.  Introduce  cartilage  strip  with  its  notch  towards  the  skin  in- 
cision so  that  it  is  between  the  frontal  bone  and  its  periosteum.  (Fig. 
274.) 

8.  Close  skin-jieriosteal  incision. 

Tico  Months  Later. 

9.  Make  an  incision  about  the  nasal  defects  in  such  a  manner  that 
two  lateral  and  one  iipper  central  flap  will  resi;lt.     (Fig.  274.) 

10.  Turn  these  over  so  that  the  skin  surfaces  will  look  into  cavity 
of  nose. 

11.  Stitch  with  catgut  so  as  to  retain  them  in  position. 


PLASTIC    SURGERY    OF    THli    XOSK    ANH    EAR. 


313 


Fig.  274. 


Fig.   270.  Fig. 

Xclaton's   operation    fnr   total    loss   of   nose. 


814  DPEnATivK  srncKr.v  of  tke  xose,  thiioat,  and  eak. 

12.  Cut  t'orclu'jul  H;i|i  with  its  jicdiclc  towards  tlie  ()i)])osito  iimcr 
t'oi'iu'f  of  tlif  ('\(\  oNcr  wliicli  till'  tia)i  is  situat('(l  as  sliowu  in  I'M;;'.  '27'). 
Tliis  fia])  contains  the  pi-fxiously  inlroduccil  cartilauc  with  its  under- 
lyinii,'  ])enostenm. 

I.'!.  Turn  the  Hap  (h)wnward,  ovci'  the  jireviously  tni'iied  flaps 
made  i'roni  tlu'  niar^in  of  the  defects.  The  flaji  shonhl  be  fashioneil  into 
a  sort  of  a  ti])  of  the  nose  by  bending  the  eai'tihige  where  the  notch  had 
))( en  <'nt  in  it,  so  as  to  make  a  proper  eohimelhi. 

14.  Stiteh  in  ])laee.     (Fig.  276.) 

15.  The  defect  in  the  forehead  is  closed  ))y  skin  graft  or  sliding 
flajis.  [Antlior's  comment. — This  forehead  defect  can  be  covered  mneli 
better  l)y  sliding  the  skin  and  making  counter  release  incisions  in  the 
liairy  i)ortion  of  the  seal]).] 

Our  Wfi-Ji  Later. 

16.  Cut  pedicle,  trim  it  and  imidant  in  existing  defect  at  tlie  root 
of  the  nose. 

Koenig's  Operation  (Indian  Method). 

1.  ]\rake  a  transverse  ineisiim  across  the  depressed  i)ortiou  of 
nose  into  the  nasal  cavity  and  dissect  loose  the  tip  of  tin-  nose,  so  as  to 
bring-  it  into  a  more  horizontal  ijosition.     (Fig.  277.) 

2.  ]\Iake  a  strip-shaped  flap  from  the  root  of  the  nose  straight 
towards  the  hair  line,  all  tissues  being  severed  to  the  bone.     (Fig.  277.) 

3.  With  a  small  chisel  cut  through  the  external  table  along  the 
course  of  the  incision  made  in  this  strip-shaped  flaji. 

4.  Take  off  this  layer  of  external  table,  periosteum  and  skin  and 
turn  it  downward  into  tlie  newly-formed  defect,  bringing  the  upper- 
most margin  of  the  strip-shaped  flap  below  the  lower  margin  of  the 
defect  and  stitch  it.  This  causes  the  skin  surface  to  look  into  the  nasal 
cavity  wdiile  the  raw  bony  surface  is  external.     (Fig.  278.) 

5.  Break  the  curved  bony  bridge  of  this  turned  down  flap  so  as  to 
give  a  curve  to  the  nose. 

6.  Make  a  lateral  frontal  flap  and  turn  it  down  in  the  usual  man- 
ner l)v  twisting  a  iiedicle  covering  the  denuded  bonv  surface.  (Fig. 
277.)  ■ 

7.  Subsequent  trimming  of  the  pedi(de  at  the  root  of  the  nose, 
with  read.instment  of  the  newly-formed  irregularities  at  this  ]wint 
must  follow,  that  is,  excision  of  the  skin  between  the  root  of  the  nose 
an<l  the  narrow  fla]i.     (Fig.  279.) 


PI.ASTIf    SllJCKIiV    or    TIIK    NOSK    ANH    KAlt. 


315 


Fi":.  27S. 


Fig.  270. 


K(icni(;'.s  operation. 


316 


OPKRATIVE   .Sl'IUiKHY   OF   THE   KOSE,   THROAT,   AND   EAR. 


Keegan's  Operation  for  Subtotal  Loss  of  Nose,    in   Cases   of   Hacked 
Noses  (Indian  Method). 
1.     Two  fia])s  are  formed  from  the  remaining  skin  over  the  nasal 
bones,  leaving  their  broad  pedicles  attached  at  tlie  bony  margins  of  the 
deformed  nose.    (Fig.  280.) 


Fig.  281. 
gan's  operation  for  subtotal  loss  of  nose,  in  cases  of  hacked  noses. 


pi^AsTic  sunr.ERY  or  thk  xose  axd  ear.  317 

"2.  'riicse  two  flaps  are  ilissoctcd  oil"  aiul  luniod  at  the  liiu.u;('il  pi-d- 
ick's  witii  tiu'ir  ilcnnal  surfai-cs  towards  the  nasal  cavity.  They  aro 
sutured  to.nether  and  into  the  Hoor  of  the  no.se.     (Fig.  281.) 

3.  The  denuded  surface  from  the  root  of  the  nose  to  wlicrc  the 
tip  is  to  be  fonned  is  now  eovcrcil  with  n  riniital  Ihip  wliieh  is  so  con- 
structed as  to  brinn"  the  pedicle  at  one  oi'  the  nthcr  inner  an.yle  of  the 
eye,  that  is,  an  oblique  flap.     (Fij?.  281.) 

4.  Suture  the  above  fla])  in  place  niakiiiu'  a  columella  out  of  the 
remaiuina:  portion  with  aid  of  the  frontal  flap  extension. 

5.  Close  the  defect  in  the  forehead  as  shown  in  Fisr.  281.  and 
cover  any  raw  jiortions  with  skin  graft  of  Thiersch  or  Wolfe. 

6.  xVfter  about  ten  days,  sever  the  pedicle  and  imjilant  j^roporly, 
reconstructing  the  skin  over  the  root  of  the  nose. 

Nekton's  Operation  for  Subtotal  Loss  of  Nose. 

1.  An  incision  in  tiie  form  of  an  A  is  made,  the  apex  of  tiie  A 
coming  close  to  tlie  hair  line  i  Fig.  2S2)  and  i-duliiniing  laterally  to  tlie 
nasal  defects. 

2.  Bv  means  of  a  fine  saw  the  skin  and  underlying  bone  of  the 
frontal  nasal  and  superior  maxilla  are  taken  along  in  the  shape  of  a 
triangular  flap  (Fig.  283),  leaving  the  attachments  at  the  alje. 

3.  It  is  then  bent  into  the  .shape  of  the  tip  of  the  nose  point  and 
folded  so  that  the  upiiermost  i^oint  of  the  flap  comes  in  between  the 
eyebrows.     (Fig.  284.) 

4.  Suture  in  this  position.     (Fig.  285.) 

5.  Close  forehead  defect  by  sliding  flails. 

Von  Langenbeck's  Operation  for  Collapsed  Nose;  Making  Supports, 
Especially  When  Soft  Parts  Are  Wanting  (Osteoplastic). 

1.  An  incision  is  made  on  tiie  side  of  the  nose  from  ihc  nasal 
pi'ocess  of  the  frontal  bone  to  the  Hoor  of  nose.    (Fig.  28G.) 

2.  Dissect  the  skin  laterally  so  as  to  expose  the  apevtura  i)yri- 
fomiis  and  the  bones  that  are  to  be  employed,  namely,  nasal  bones  and 
the  nasal  ])rocess  of  the  superior  maxilla. 

3.  With  a  small  saw  or  chisel  cut  from  above  downwards  a  small 
strip  of  bone  on  each  side  of  tln'  ni.nuin  of  the  aiiertura  in  such  a 
manner  as  to  leave  its  lower  attachnicnt  at  the  superior  maxilla.  (Fig. 
286.) 

4.  Elevate  these  two  pieces  of  bone  outward  and  bring  over  them 
the  previously  dissected  skin  which  is  further  sutured  to  these  bone 
l)articles.     (Fig.  286.) 


318  Ol'KI-.ATIVK   srnOERY   OF   THE   NOSE,   THROAT,   AND   EAII. 


Fig.  2K].  Fig.   285. 

X(Matn]rs  uiirnitiuii  for  sul>tot:il  loss  of  .nose. 


pr.ASTic  sriUiKiiV  ni'  niic  XdSK  an'h  kau. 


:;i!i 


.").  A  similar  prorodiin'  is  pniotifcd  on  tlii'  iiasiil  Ixnifs,  whii-h 
aic  usually  dcpn'sscd.  Tlicv  arc  sawed  nr  ciiiseli'd  otV  I'niui  tlie  nasal 
jirocossos  of  till'  su|ii'iini-  maxilla  and  cli'vattMl,  Icaviii;;  tlicir  attacli- 
iiioiil   witli   till'   fi-unlal    \>n\\r  us  a   -(Hi    nf  liinii-f.      {V'lii.  "JS?. ) 

t).  l-'iinii  a  iHdiM'i-  lniclir;id  Map  and  ftiM-i  thi>  iicwly made  lioiiy 
siippiwt.  and   -nlui'i'   in   llic  n>nal   nianiMT. 

Schimmelbusch's  Operation  for  Total  Loss  of  Nose. 

].  ( 'ul  uut  a  rliunilniidal  >liapc(i  llnp  IVcnn  llii'  Inivhriid  with  thr 
lu'oad  jiart  aliovf,  im-asnriui::  '2  to  o  cin.  lictwccn  I  lie  niari^in-  lifldw  nnd 
(i  1(1  7  cm.  at  its  upper  part.  Its  leuiitli  should  depend  mi  the  len-tli  of 
tiu'  nose  to  he  <'o\('red.     This  incision  includes  the  perio>teum. 


Fig.  -W!.  y^ii-  -'^'i- 

Von     Laiificiiliecli 's    operatidii     fm     ciilhiiiscil     luisc:     niakinji    .siii>i)orts, 
especially  when  soft  parts  are  wanting. 

2.  By  means  of  a  broad  cluse!  a  thin  plate  of  liouc  is  taken  away 
with  tliis  flap;  in  most  instances  it  will  he  in  several  jiieccs,  altliouij;li 
endeavor  should  he  made  to  keep  the  perin>teuin  attached.     (Fig.  288.) 

.'1.  Turn  this  skin  hmie  ll;ip  down  and  in  order  to  prevent  these 
hone  plates  from  I'aliini;-  olV.  a  sort  of  lattice  \voii<  nf  -ilk  thread  sliould 
he  passed  abont  this  flap  and  co\ered  willi  -au/.e  to  allow  i;ranidation 
to  form. 

4.  Cut  out  two  curved  skin  tlajis  as  shown  in  Fi.u;.  2SS,  to  allow 
the  slidiiif^  forward  of  the  lateral  skin  flap  for  the  closure  of  the  frontal 
defect. 


320  OPERATIVE   SrELIEl!V   OF   TTIE   NOSE,   THROAT,   AND   EAR. 


Fig.  289.  Fig.  290. 

Sehinimelhuseh  's  operation  for  total  loss  of  noso. 


pi.ASTK"  sri!(!i:i!V  (H-    iiir.   misk  an"i>  r.Ai;. 


321 


5.  Contiinio  iiioisioii  up  to  tlio  pcriiistt'inn  in  a  cuixd  liiioar  nian- 
nor  bai-k  of  llio  car  ami  looson  the  t'liliiv  latoral  Hap.  (Fijr.  289.) 
'riiis  is  done  on  liotli  sitlos. 

ti.  Slide  tlu'  two  lali'ral  Haps  so  as  to  inaki'  tlicm  iiicct  in  tlio 
center  of  the  forehead  and  also  Join  the  sUiii  where  the  two  little  flaps 
were  removed.  As  a  result  there  will  l)e  two  small  ilefecls  on  tlio  side 
of  the  head,  which  can  he  aUowed  to  jii-amdale  and  can  lie  eoi'i'ected 
subsequently. 

Four  to  Si.r  Wrels  Later. 

7.  I\v  means  of  a  saw  divide  tlie  Ixmy  pdilinn  of  ilie  nose  to  lie 
formed,  and  shape  it  in  the  form  of  a  Ironuh.  In  the  event  tliat  tiie 
pedicle  is  a.aain  ailherent  at  the  loot  of  tin'  nose,  it  should  he  thor- 
oughly loosened  and  tlie  flap  Ini'ned  with  its  dermal  surface  ontwanl. 
(P'ig.  289.) 

8.  To  form  the  eolmnella,  dissect  off  from  each  side  t)f  tiie  ])yri- 
foiTu  aperture  two  skin  flai)s  and  unite  them  as  shown  in  Fig.  289. 
This  will  leave  their  pedicle  attachment  at  the  usual  insertion  of  the 
columella  and  their  free  end  is  to  be  attacheil  to  the  newly-fonned  tip 
of  the  nose. 

Three  Weehft  Later. 

9.  Freshen  up  the  lateral  )ioi1Jon  of  the  defect,  esjiecially  at  the 
apertura  pyriformis  and  dissect  away  the  skin  so  as  to  lay  hare  the 
bony  margins  of  the  defect.  The  good  result  of  this  iiroce<lure  de- 
pends \\\nn\  this,  since  the  implantation  of  the  bony  jiortion  of  the  new 
nose  on  a  raw  and  bony  area  makes  a  substantial  support.  Sutures 
through  the  bone  aic  additional  supports  for  good  union. 

1(1.  Pass  a  wire  through  the  lower  portion  of  the  nose,  trans- 
versely, and  fix  by  two  small  rolls  of  gauze  or  small  rubber  tubing  so 
that  the  wire  does  not  oit  in.  The  pui"pose  of  this  wire  is  to  insure  a 
roof-like  fomi  to  the  bridge  of  the  nose.     (Fig.  290.) 

11.  Sever  the  pedicles  of  the  frontal  flaps  of  the  nose  and  jilace 
them  into  the  defect  where  the  two  lateral  flajis  Join  in  the  middle  of 
the  forehead.     (Fig.  290.) 

Schimmelbusch's  Operation  for  Saddle-back  Nose. 

1.  Prepare  tlie  frontal  (skin-bone)  Hap  in  the  same  way  as  in  the 
Schinunelbusch  o))er;ilion  for  total  loss  of  nose,  ami  make  the  lateral 
flap  in  the  same  manner,  uniting  the  created  defect  newly-formed  in 
similar  manner. 

2.  Turn  the  frontal  flap  directly  down  without  twisting  the  ped- 
icle, that  is,  the  skin  downward  and  bone  exteniallv,  cover  the  flap  with 


3'2'2  (IPKIIATIVK    snU'.KllV    OF    THK    XOSK,    TIIKOAT.    AXD   EAR. 


Fig.   292.  Fig.   2il3. 

SehimmelliusiC'li'E  ojjcratioii   for   saddleback   nose. 


IM.ASTK'    sri!(iKI!V    OI"    TI I K    XdSK.    AN'r>    I'.AK. 


323 


till'  thread  liitticc  work  to  prevent   tlie  (lislodnciiieiif  of  tlie  Ikhh'  ami 
w  ra])  the  w  lioU'  thi|)  in  gaii/.e  to  alhiw  the  hone  to  ,u,ranuhile. 

Oil,'   Jl'.r/,    L,il,  r. 

I!.  Make  a  vertical  incision  in  the  middle  of  the  hri<lii;e  ol"  the  nose 
and  cat  loose  suhcntaneonsly  tlic  lower  pari  of  the  carlila;,Mnons  jnir- 
lion  of  tho  nose,  so  as  to  lu-inu  <lown  the  ti]i,  makiuL;'  an  opening'  into 
the  nasal  cavity  wit  li  tiic  nostrils  lookinu  dow  nw  ard.     (  l-"i,y.  L'iM  . ) 

4.  Freshen  np  the  hony  apertnra  pyriformis  and  dissect  the  skin 
freely  from  the  siile  of  the  nose. 

.').  Saw  and  lireak  the  h(iny  |)ortion  of  the  iVontal  llap>  in  snch 
fashion  as  to  give  a  roof  like  appearance.     (Fig.  291.) 

(i.  To  insnre  healing,  trim  off  the  dermal  layer  of  the  frontal  llap 
where  it  will  come  in  contact  with  the  ti-.-ne>  ahont  the  apertnra  pyri- 
formis. 

7.  riace  the  frontal  llap  in  jiosition  lietwcen  the  dissected  lateral 
skin  mariiins  of  the  nose  ;ind  lirndy  aL;ain>t  the  apertnra  pyriformis, 
where  an  anchor  >ntuie  may  he  pl.-iced  ;iiid  lironght  ont  at  the  onter 
corner  of  the  ahv.     (Fig.  -Jii-J.) 

One  Week  Lnfcr. 

8.  Sever  the  pedicle  at  the  lotit  of  the  nose  in  snch  a  manner  as 
to  utilize  as  nuich  of  the  tnined  over  skin  as  ])()ssihle  to  lit  into  the 
still  remaining  defect  hetwcen  tiu'  eyes,  whore  the  two  lateral  parietal 
llap>  come  to-ether.  and  then  sntnre. 

'J.  h're^hen  nji  the  lateral  skin  margins  of  the  nose  and  hring'  to- 
g:ether  over  the  middle  of  the  nose.     (Fig.  293.) 

Sir  Watson  Cheyne's  Operation  (Indian  Method). 

1.  An  inci-ion  i>  made  in  the  median  line  (if  the  nose  o\-er  the 
cartilaginons  portion,     (h'ig.  2114.) 

2.  Two  transverse  incisions  are  made  at  each  end  of  the  lirst  in- 
cision, forming  two  lateral  flaps  when  dissected,  like  an  open  door. 
(Fig.  294.) 

3.  Dissect  thesi'  lateral  Haps  and  take  along  any  fragments  of 
nasal  hones  or  periostenm  that  ma\  he  .ittached  to  them.     (Fig.  29.").) 

4.  Sever  the  cartilage  finm  tlie  hcmy  poition  of  the  external  nose 
and  cnt  into  the  septnni  so  as  to  jmll  dow  n  the  point  of  the  nose  in  the 
pioper  shape. 

.').  Two  \-er(ical  incisimis  arc  now  ma<le  slii;htl>'  aiio\c  the  root 
of  the  nose  and  aliont  <inecii;htli  of  an  inch  from  the  median  line,  as 
far  n|i  as  the  line  of  the  hair.     A  third  tran>\('rse  incision  nnites  these 


324  OPERATIVE   SITRGERY  OF  THE   NOSE,   TIIKOAT,   AND   EAR. 


Fig.  294. 


Fig.  296. 


Sir  Watson  Cheyne's  operation.      (Indian  method.) 


I'l.Asiu    >ri;oEr.Y  of  tiik  xose  and  ear.  31'") 

Iwo  viTticiil  OIK'S  at  llu'  liiiir  liiu'.     Tlicsc  lliri'c  incisidiis  dixiilc  nil  llic 
structures  dowu  to  tlio  liono.     (Fiir.  'JiU. ) 

6.  Insert  a  narrow  cliisi'l  alniiii-  tin'  margin  of  tliese  tliree  in- 
cisions and  sejiaratc  ,i  iKnliiiu  >,{'  thr  cxiii  nal  talile  of  the  frontal  bono, 
Ii'avinu'  it  attached  lo  tiir  iicriostcniii  and  tin'  remains  of  the  lla|i.     (Fisif. 

7.  This  whole  tlaji  is  now  turned  downward  so  tiiat  the  skin  i< 
looking  into  the  nasal  cavity  while  the  outer  surface  comprises  the 
denuded  bones. 

S.  Shave  olV  the  epidermis  at  tlie  voot  of  the  nose  as  well  as  at 
the  uppermost  jMiitinn  nf  ilii>  tnrin'<i  down  llaji  so  that  tiiese  two  may 
adhere  at  this  point. 

9.  Suture  the  lowest  point  tif  this  tnined  down  liap  to  tiie  fresh- 
ened cartilaginous  portion  of  the  nose  that  was  pulled  down,  thus 
closing  the  nasal  defect.  Care  should  be  exercised  at  this  point  not  to 
bend  the  upper  pedicle  loo  aentely  ami  m)t  to  lia\e  any  tension  what- 
soever. If  there  be  trouble  of  this  sort,  two  little  ineisious  may  be 
made  on  the  side  of  the  nose  from  the  lia>e  of  ihi-  iljip  and  the  tension 
thereby  relaxed.     (Fig.  296.) 

10.  Unite  the  defect  on  the  forehead. 

11.  The  lateral  flaps  are  now  replaced  and  united  over  the  raw 
iiony  surface  of  the  forehead  flap,  also  above  and  below.     (Fig.  297.) 

Ticd  or  Tlnce  Weelis  Later. 

12.  Tlu'  jiedicle  is  cut,  tnrned  back  to  liil  up  tln'  defect  and  any 
irregularity  trimmed  down  and  corrected;  an.\'  graimlating  surtace 
may  be  covered  by  skin  graft. 

Von  Hacker's  Operation  (Indian  Method). 

1.  <)utliue  the  usual  llap  iVoiii  forehead  with  pecjicle  at  the  root  of 
the  nose. 

2.  Dissect  tin'  skin  on  the  three  IVee  margins  of  the  llap  to  a 
point  iu  the  median  line  mea>ni-int;'  s  mm.  in  width  an<l  the  full  length 
o|'  tile  tla|i:  tlii>  portion  i>  to  form  the  ^uli>e(|nen1  bony  support  of  the 
innvly-fonned  nose. 

'•i.  The  dissected  skin  is  now  sutured  temporarily  iu  tiie  median 
line  by  two  or  three  interrujited  sutures  and  a  few  small  ))ins  driven 
into  the  bouc-periosteal  flap  (  Fig.  29S)  in  order  to  facilitate  its  dissec- 
tion. 

4.  By  means  of  a  chisel  tliis  lioue  periosteal  skin  llap  is  now 
severed  up  to  the  root  of  the  nose,  where  the  pedicle  only  consists  of 
skin  and  jieriosteum,  in  order  to  be  aide  to  twist  it  easily.     (Fig.  299.) 


oL'G  (IPKIIATIVE   rtl'EGEKY   OF   THE   NOSE,   TIIKOAT,   AXD   EAR. 


Fig.  300. 

Von  Haeker's  operation.     (Indian  mothod.) 


IM.ASTIC    sri!(iK.i;V    OK    TIIK     NOSK    A  N I  •    K.AI:.  .._( 

.J.  lirciik  away  the  iMitiic  llap  ami  lutati'  dnw  iiw  aid  iiiln  tin- 
|iropor  ])osititiii,  liaviiii;-  in'cviously  |prc|iari'(l  llic  cldVct  I'm-  iininii  l.y 
rn'shciiiiiti'  up  llic  iiiaruins  ami  tlir  i-ciiiaiiis  nt'  the  si'iitniii  with  wliicli 
till'  lioiiy  luiiln'c  is  tt)  roinr  ill  (•(intact.  This  lniii>'  strip  is  iirnkcii  at 
the  hiwcr  |iciitiiin  and  a  |ii(i|ici'  iminl  of  ihi'  misc  i-  InrnKMl.  It  is 
siiturcil  iiilii  the  llimr  oi'  the  iidx'  ami  a  ciilnniclla  aiui  ala'  arc  i'liniiod 
from  tile  skin  llaj).  Kiildicr  tuhcs  arc  inserted  into  nostrils  to  irive 
siiiii.e  to  them.     (Fi.<?.  :!()().) 


Fip.  W2. 

(lii.li:iii    nirtliiicl.i 

Sedillot's  Operation  for  Total  Noss  of  Nose  (Indian  Method). 

1.  Form  a  tongne-sliapcd  llap  IVom  the  upjicr  lip.  not  ijoiiifi: 
tliroiiji'li  the  mui-ous  memiiraiic.  plaeinii-  the  jiediclc  at  the  nasal  Hoor. 
(Fi.tr.  •■!l>l.) 

'2.  Form  a  forehead  llap,  takinj:;  care  to  make  a  loiiiier  median 
llaj)  lor  tlie  fonnation  of  the  colnmella. 

;'..       Freshen   up  tin-  na>;d   ddVet. 

4.  I.rini;-  down  rnmlal  llap  and  -ntnrc  in  lalcrally.  and  to  f(U-in 
the  columella  snturc  central  llap  to  the  little  llap  iVdUi  the  lip  in  such 
a  manner  that  there  is  skin  surface  externally  as  well  a.->  in  the  nose;  in 
iitlicr  wiirds.  one  on  top  of  the  other.     (  Fiu.  'M)'2.) 


IV.     Double  Tran.splantation  Method. 

A  skin  Haji  )nay  first  he  made  fi-om  the  chest  or  ahdomcn  and  at- 
tached to  a  part  of  the  hand  or  forearm,  and  after  it  li.is  healed  un  and 


328 


OPEUATIVE   .SUIUiERY   OF   THE   NOSE,   TIIIIOAT,   AXD   EAR. 


good  circulation  has  been  ostablisslicd,  it  is  severed,  and  tlicii  attached 
to  the  nose  as  in  tlie  Italian  method.  Or  a  toe  from  which  the  nail  has 
been  removed  is  implanted  into  the  palm  of  the  hand,  and  after  it  is 
thoronghly  healed  it  is  severed  and  made  ready  to  use  in  constructing 
a  firm  support  for  a  nose.  Bone  which  has  been  removed  from  an  am- 
putated leg  and  formed  in  the  shape  of  a  nose,  implanted  under  the 
forearm  below  the  periosteum  of  the  ulna,  is  prepared  in  the  fonn  of 
a  pedicle  after  it  has  united  and  remained  viable  and  is  then  sutured 
into  a  nasal  defect,  as  in  the  Italian  method.    A  similar  method  is  em- 


Fig.  .303. 

Steiutlial's   oporation   for   total   loss   of  nose.      (Double   tiniisiilaiitntiou    iiiotliod.) 

ployed  in  implanting  pieces  of  cartilage  under  the  skin  and  periosteum 
of  the  forehead  Itefore  making  the  frontal  flap. 

Steinthal's  Operation  for  Total  Loss  of  Nose. 

1.  Make  a  tongue-shaped  flap  from  the  sternal  region  with  its 
pedicle  towards  the  sternal  notch,  measuring  5  cm.  at  its  free  end  and 
3  cm.  at  the  pedicle  end,  the  length  being  about  12  cm.  The  flap  is  com- 
posed of  skin  and  periosteum.    Suture  the  defect  over  sternum  in  part. 


PLASTIC    Sritl'.KUY    OK    TlIK    XOSK    AXI)    KAlt.  329 

•J,     Make  an   incision   tliroufjli   tin-  si<lii   uf  tlir   ruicaiiii   near  thf 
\\ri>l   ami  ever  llii'  radius  to  accoinniodatr  llic   I'lcr  cinl  dt'  liic  ahovo 

Ilap. 

;;.       SulUl-r   ill    tlli>    tVrr   iMld    cif   lllc    tlap    I'"!-   >U  I  im 'i  |  llrllt    t  I'a  n>|  ila  II 1  a - 

liiiii.     I  Fiir.  •■!i»:i.i 

4.  Ai)|)ly  inmuiliilizin^-  plaster  of  I'aris  jai'icct. 
'fivclre  Days  Later. 

5.  Sever  pedicle  from  stcrnnni  and  Icavf  it   nnal  larhcd  in  allow 
]ierfect  circulation  to  he  estal)li>ii(d  in  thr  tlap  I'm-  \\\>>  m-  three  days. 


Fig.    305.  Via.    -MM. 

Kaiisch's  operalion   for  collapscil   ikisc.     (Double  liiinspiairtiition   motlnHl.) 


(i.       |-'re>lle|i   |||>  the  Slirl'aei'  at   the  nasal  defei-t. 

7.  Suture  free  iMid  (if  Map  situati'i!  ni\  the  forearm  to  this  prc- 
jiaivd  siii'faer  almiit   the  iia>al  defect.      (I'^i-'.  'M)4.) 

s.  Appl\'  aiiain  a  retention  |ila>ter  of  i'aris  jacket  for  aimut  one 
week  or  ten  days. 

9.  Sever  the  Haj)  from  the  foreaim  and  sntnrc  in  ahoiit  the  re- 
mainintr  nasal  defect  to  form  a  jiroperly  shaped  nose,  inclndintr 
columella  and  alar  slsin  liniuLT. 

Kausch's  Operation  for  Collapsed.  Nose. 

1.  li'eiuove  tin-  iiail  nf  the  fourth  toe  of  the  >ame  >ide  as  the  hand 
tJuit  is  to  lie  employed.  A  portion  of  ihi'  skin  from  llie  tip  of  tin'  toe  is 
tui-iied  hack  to  olitaiu  a  uond  law    >urfai'e. 


330  oi>ei;ativk  srnciERY  of  the  nose,  throat,  and  ear. 

2.  Make  an  incision  in  the  tlicnar  cniincncc  of  llic  palm  of  the 
liand  of  a  ]iro]K'r  size  1o  accoinnuxlate  tlie  tip  of  tlie  toi'. 

;!.  Itiini;-  hand  and  loc  together  approximating  the  ti]i  of  toe  to 
tile  ineision  and  snture  well  on  all  sides  of  the  skin. 

4.  Place  a  retaining'  device  either  of  plaster  of  Paris  or  leather 
to  keej)  the  parts  immobile. 

Tiro  TFrrA-.s-  Later. 

5.  Sever  the  toe  at  the  metatarso]ilialangeal  .joint,  leaving  it  at- 
tached to  the  hand.     (Fig.  305.)     Close  defect  in  the  foot. 

Tuo  Ddifs  Later. 

6.  Freshen  n]i  the  hony  surface  at  the  floor  of  the  nose  and  the 
skin  on  the  side  of  the  nasal  defect. 

7.  Bring  hand  in  proximity  to  nose  and  suture  the  free  end  of 
the  transplanted  toe,  which  has  also  been  freshened  on,  into  the  bone 
exposed  at  the  prepared  nasal  defect.     (Fig.  306.) 

8.  Retain  by  plaster  of  Paris  bandage  as  in  the  Italian  method. 

Tn-o  Weel-.'^  Later. 

9.  Sever  the  attachment  of  the  toe  to  the  palm  of  tlie  hand  and 
close  this  temporary  defect. 

10.  Eemove  the  skin  from  transplanted  toe  from  the  jiart  that 
is  to  come  in  contact  with  the  subcutaneous  tissue  of  the  ridge  of  the 
nose.  If  the  mass  of  bone  is  too  large  one  may  bite  out  a  portion  and 
also  sha])e  it  in  the  form  of  a  cohnnella  and  ridge,  giving  the  nose  a 
proper  shaped  jjoint.  Suture  the  distal  end  towards  the  root  of  the 
nose. 

11.  Subsequent  smaller  corrections  of  making  jirojier  shaped 
nostrils,  etc.,  should  be  done  not  before  two  weeks,  wlu'u  the  circula- 
tion is  well  established. 

V.     Finger  Method. 

In  cases  where  a  gi^eater  part  of  the  bony  portion  of  the  external 
nose  is  absent  and  most  of  the  soft  parts,  the  employment  of  the  finger, 
sacrificing  this  member  for  the  formation  of  a  nose,  has  been  followed 
by  good  results.  The  cases  especially  suitable  for  this  operation  are 
those  in  which  the  greater  part  of  the  alae  and  in'obably  the  skin  por- 
tion of  the  tip  of  the  nose  are  still  present,  even  though  this  latter  por- 
tion be  markedly  draAvn  in  and  adherent. 

Watt's  Operation  for  Subtotal  Loss  of  Nose. 

1.     Sever  the  columella  at  its  attachment  to  the  upper  lip. 


PLASTIC    SlUCKUY    OK    THK    NOSE    ANH    EAR. 


331 


2.  T;iki'  llu'  Ift't  little  iiiip'r  ainl  rciiinvc  its  n.iil  .•mil  matrix,  also 
tile  skill  t'roiii  its  tip  aiiti'riorly. 

'■'•.  I';i>s  this  linger  tlirou^^l I  rriiiii;iiii  nf  tip  nf  nusc  ami  li\  at  tin' 
root  of  tlu'  iioso  eloso  to  tlic  frontal  hour  liy  misuis  of  sil\i'i-  uii-c,  an 
aiva  lia\iiig  been  pri'iiafi'il  in  tins  ii'uion.     (  l''i,Lr.  -inT.) 

4.  Appily  a  iilastci-  (•a>t   to  Imld  paft>  IminoliiliziMl  in  place. 

Tuu    Wcks   L,:l,  r. 

5.  Amputate  tiii^'ef  at  iiietacai-jiophalaniceal  joiiil  ami  close  de- 
fect in  luuul. 

A  Few  Dai/s  Later. 

(i.  Trim  down  the  free  end  of  the  liuii-er  so  as  to  make  it  narrow- 
enough  to  obtain  two  separate  nostrils. 


Fi^,^  307. 
Watt's  nppr;itin!i  for  siiMotiil  loss  (>f  nc 


7.  I'lish   tliis  end  of  the  lingiT  into  the   nasal  caxity  and   fix   liy 

anothel-  MltUfe. 

8.  Suture  l)ack  the  pri'viously  se\ei-ed  columella  to  the  liji  by 
refreshing  their  surface. 

fhn    Week  Later. 

'J.  Remove  skin  I'lom  doisum  of  the  now  healed  in  linger  at  the 
nasal  defect. 

10.  A  flap  from  the  forearm  is  made  and  >ntiiied  in  above  the 
defect,  fixed  a,gain  by  plaster  jacket  and  tieaied  a-  in  any  Italian 
method. 


33l2  OPKr.ATIVK    .Sl'KCEKY    OF    THE    XOSli,    THROAT,    AND    EAR. 


Fig.   309. 


I'lg.    310.  Fig.    311. 

Wolkowitseh 's  operation  for  total  loss  of  nose.      (Finger  mt'tliod.) 


ri.ASTIC    SlR(iKI5Y    dl'    TIIK    NdSK    AXU    KAl!.  ■  •'•' 

Wolkowitscli's  Operation  for  Total  Loss  of  Nose  (Finger  Method). 

I.  Take  till'  roiirtli   liii-rr  nl'  tlir  li'l't    1:;umI. 

Ll.      Make  a   iiiriliaii   incisidn   ii\ri-   llif   iliii->al   Miil'a iT   tlii'   >aiiic 

I'roiii  tho  iiU'tacariKiiilialaiiural  jninl  \i>  llic  nail,  lliidimli  llic  skin  ainl 
siilx'utaiu'ous  tissiu'. 

."!.      Disswt  loosi'  to  I'itliri-  side  ricfly. 

4.  lu'inovc  tlu>  nail  ami  lie  sine  n['  the  rcinnxal  nl'  ail  <>['  its  matrix. 
TiMulon  must  not  he  tlisturl)0(l.     ( Fiji'-  •J*'''^.) 

.").  l\onu)\i'  the  skin  from  tlu'  tip  of  tlic  rniiiff  in  iVnnt  I'nr  its 
attaclinicnl   al    tiir   i-.Hit   df  the  nose. 

(1.  Split  tin'  skin  and  nndcrlyhi.n'  tissuos  tlirouuli  to  tiic  liuui'  in 
the  median  line  at  the  rout  of  tlie  nose,  and  separate  iTPoly  to  either 
side,  includin:^  tlu'  margins  of  tlu'  icnnaininu'  apcrlnra  iiyriformis. 

7.  In  the  hoiiy  strnclnrcs  at  tin'  rout  of  tin'  no-i'  make  a  <lfiit  hy 
means  ol'  a  liuimv,  into  wliieli  tin'  tip  of  the  rmi^ei-  will  lit  so  as  not  to 
make  a   pereeptihle  Inimp  at   tliis  jpoiiit.     (  l-'ii;'.  .'If'.i.) 

5.  I'.i-im;'  tile  linLii'i-  to  the  jnvpared  aiea  of  the  nose  and  tuck  its 
skin  t!a)is  helnw  the  disserted  latei'al  Map  alMHit  the  apertura  pyri- 
fonnis,  the  tiji  of  the  finger  being  litteil  into  the  ilepic-sioii  at  the  root. 

!l.  fasten  the  linger  at  the  root  li\  sutnics,  as  in  fig.  310,  and 
stiteli  the  >kin  llaps  of  tlie  finger,  w  hieh  are  tm-ked  nnder  the  dissected 
skin  of  tlie  nose  defect,  witli  two  mattnss  sutnics  on  eacli  side. 

10.  Close  the  median  ineisioii  at  the  root  of  the  nose  as  far  down 
oxer  the  (inner  as  ]iossihle. 

II.  Place  a  ipiantity  of  marly  (Seoteh  izaii/e)  helow   the  linger  li> 

liold  it  ii|i  in  the  siiape  nf  a  imse  and  pi; a  di'essin-'  oxer  the  surface. 

Then  apply  a  lixation  iiandage  as  in  aii\    Italian  operation. 

Nine  Ddifs  Liitir. 

\'l.  K'enioNc  the  stitches  and  I'Xleiid  the  ineision  over  the  dorsum 
of  tiie  hand  so  as  to  expose  the  entire  nietaeaipophalani^cal  joint  f«n- 
excision. 

l.'i.  Dissect  tlie  skin  laterallv  and  inci>e  it  on  eithi'i'  side  of  the 
linger,  hut  do  not   sever  in   t'ldiit    at    this  time. 

14.  During  the  next  live  days  in  twn  separate  sittings  the  skin 
l)edicle  is  severed   and  the  metacarpophalangeal   joint    disarticulateil. 

1.1.  ('over  the  defect  on  the  hand  as  in  a  regular  disarticulation 
operation    li\-   the  remaining  skin   anteriorly. 

K;.  I!end  and  shape  the  now  altached  liuLier  iu  the  rorm  o|'  a  nose, 
place  some  mme  niarl\  hehiw  it  and  allow  it  tn  remain  fnr  thi-ee  more 
days  for  lirmer  attachment,     (fig.  .'111.! 

17.      I'end  sliai-pl\    lietweeii  the  lir>t  and  secnnd  phalangeal  joints 


334  OPERATIVE   SURGERY  OF   THE   XOSE,   THROAT,   AM)   EAR. 


Fig.  312. 

Von    Esmareh  's   operation   for   collapsed   nose   or    absence   of   the   pre- 
maxilla  or  an  anterior  perforation  of  hard  palate. 


Fig.  313.  Fig.  314. 

Clavicle   method.     (Gustav   Mandry.) 


n.AsTic  sriKiKin'  III-   Tin:  xosk  ank  k.ai; 


3:}") 


to  siu-li  a   di'iii-cc  thai    \hr   lii-st    phalanx    may   he   |ni>hi'il   iiiln   the  nasal 
cavity. 

IS.  I'n'parc  tlic  Ihnir  ol'  the  im-c  aihl  if  thi-ir  i-  a  iinilion  nf  >f\i 
turn  romainiim',  rriiinxr  all  tin'  inucnus  iin'iiilu-aih'  ami  I'Sposc  ils  Imhi.v 
surface. 

lit.  Ju'inovc  all  the  skin  and  uraniilatidiis  rrmii  that  iml  of  the 
liiiii'i'i-  that  has  licmi  ili-articiilalcd  ami  inisji  ii  intn  the  imsf  auaiust 
the   raw  surface-   i]rc|iari'i|   at    the   thmr. 

I'll.  Ihsscrt  miw  the  lateral  niari^ins  of  tin'  a|iert\ii'a  |iyrifiii-iiiis 
hiw  <lii\\ii  to  \\diere  the  ahi'  are  tn  he  I'lirimMJ.  and  tnek  nnder  the 
reuiaiuinu'  |i<irtiiin>  nf  the  skin  tlap  nf  the  linL;-er.  wliieli  are  again 
attaidu'd  hy  dUe  mattress  suture  on  each  side. 

ill.  (nver  the  entire  denuded  surface  of  this  huny  reeduslrueted 
framework  with  a  K'rause  llap  iw  with  any  tlaj)  either  from  the  i"ore- 
liead  or  arm.  further  >liL;ht  enrreetions,  as  foi'matiou  o(  nostrils  and 
('0\-er   for   ediunu'lla,    are    >uliseipieutly    pei-fuiMued. 

Von  Esmarch's  Operation  for  Collapsed  Nose  and  When  There  Is  Also 
Absence  of  the  Premaxilla  or  an  Anterior  Perforation  of  Hard 
Palate. 

1.  K'eimive  the  nail  of  tln'  little  fumer  (if  the  h'ft  hand  and  freshen 
up  the  tip  autei'iiirlv . 

2.  Freshen  u|i  the  surface  on  the  inner  side  of  the  tiji  of  the 
nose  and  what  is  still  existiuL;-  on  the  floor  of  the  nose  anteriorl}.  If 
nose  is  ri'ti'aeted.  it   slioidd  111-  freely  dis>ei-ted  and  made  mn\ali|e. 

.').     Fasten  the  liu.u'er  with  wire  to  the  hone  of  the  superior  ma.Kiila 
about  the  <lefect  and  stilidi  to  the  soft  part  of  the  nasal  tip.     (  l-'ii;-.  ol'J.) 
4.      Apply   a    plaster  .jacd-jet. 

Tun    Wrrl.s    Ijltrr. 

.").  I)isarti<'ulate,  usually  at  tiu'  .jnnetion  of  the  seeon<l  and  first 
jihalaiiLZfal  .joint. 

'I'lrn  nr   Tin,  r  Dims  Ldhr. 

(I.  |-'re>hen  up  the  mari:ins  of  the  )iei-foration  or  defect  at  the 
I'oof  of  the  month  and  sutni'e  in  the  properly  prepare(|  stump  of  the 
linger. 

VI.     Clavicle  Method  (Gustav  Mandry). 

I.  form  a  lla|i  o\-er  the  region  of  thi'  (da\i(de,  consisting  of  skin 
and  snhcutanecnr'-  connective  li>~ne  and  of  the  |ieriostenm  ami  hom- 
of  the  (davicle.  Thi'  hroad  pe.jicle  is  sitnat.'.l  o\cr  the  shoulder  and 
the   IVi'c   iMid   at    the   -t  e  rnoc  la  \  i  c  n  la  i'   ai1  icniat  ion.      (FiLi'.   '■'>]'■'>.) 


336  OPERATIVE   ST'RGERY   OF   TlfR   NOSE,   T7IR0AT,   AND   EAR. 

2.  Dissect  this  skin  flap  iip  to  the  upi)or  ami  lower  luariiins  of 
the  <'laviolo,  loaviiis'  it  lioi'c  attachod  to  the  bono. 

3.  Cliiscl  (ir  saw  out  a  slixci'  of  tlic  t'laxidt'  measuring  4..")  cm. 
loim'  l)y  ()..")  cm.  -wiili'  (iii(licat('(|  liy  r/-r/'-/>-//' — Fin'.  .'!1.'!)  near  the  stcnio- 
claxiciilar  ai'ticiilatioii  without  ilctacliiiii;-  tlic  skin  and  ]i('i'iosti'un]. 

4.  In  tlie  free  end  of  tliis  sliver  two  small  holes  are  ))ore(l  for 
subsequent  anchorage  to  the  nose. 

5.  In  the  middle  of  this  large  flaii,  right  over  the  clavicK',  a  flap 
of  skin  and  subcutaneous  tissue  is  made  in  the  form  of  a  window, 
directing  the  pedicle  towards  the  sternocla\icular  articulation,  in  order 
to  turn  it  on  the  under  surface  of  the  bone  sliver,  in  that  way  assuring 
its  nourishment  from  both  sides,  besides  subsequently  forming  a  dei'mal 
lining  for  the  interior  of  the  nose.  This  central  flap  is  turned  180 
degrees  and  made  to  come  beyond  the  tenninal  end  of  the  bone  sliver, 
where  it  is  fastened  with  the  skin  above,  thus  suri'ounding  this  bone. 

6.  Close  this  newly-formed  central  l)uttonhole  in  the  large  flap 
by  a  few  interrupted  sutures.     (Fig.  ;'>14.) 

7.  Allow  this  whole  flap  to  rest  over  its  dissected  area  where  it 
Avill  attach  itself  temporarily,  getting  additional  nourishment  for  its 
sustenance. 

Four  Dai/s  Later. 

S.  Separate  this  whole  ])edicle,  including  tlie  doui)le  skin  covered 
bone  sli\er,  and  liberate  it  more  freely  by  commencing  the  outside 
incision  over  the  shoulder  and  back,  thus  giving  a  greater  motion  to 
the  flap  f(n-  its  adaptation  to  the  nose  region. 

0.  Freshen  up  the  nasal  area,  making  a  pocket  at  the  root  of 
the  nose  in  which  the  clavicular  bone  sliver  will  be  slipped. 

10.  F\])ose  this  bone  sliver  and  place  two  strong  sutures  through 
tlu'  lioles  which  have  been  previously  drilled. 

11.  Turn  the  head  towards  the  shoulder  where  the  fla]i  is  formed, 
and  bend  it  slightly  downward  so  that  the  flap  can  be  lu'onglit  in  close 
appro.Kimation  with  the  nose  without  any  tension. 

12.  Bring  the  tAVO  strong  sutures  through  periosteum  and  skin  at 
the  root  of  the  nose  and  tie  over  a  pad  of  gauze,  fixing  the  bone  sliver 
in  the  newly-formed  pocket. 

K!.  Aii]ily  a  few  ad<litional  sutures  at  the  top  and  side  of  the  nose. 
(Fig.  314.) 

14.  Fix  the  head  in  the  twisted  flexed  position  in  a  plaster  cast, 
as  in  the  Italian  operation,  and  ])rovide  proper  windows  in  the  cast 
for  feeding  and  for  dressing  of  the  wound. 


PLASTIC  sri!(;i:i!Y  111'   riiK  nosk  anh  i:ai'.  33r 

0,n    Week-  Lain: 

]').  Sover  tilt"  brid.HL'  ja'diclf  at  tlic  phu-c  when'  il  is  .l.ciili'.l  that 
luoiHT  skin  flaps  may  be  made  to  complete  thf  ahf.  (•oluimlia.  clo. 

Hi.  l>isso<'t  off  the  oi)iclorniis  laterally  IVdiii  tlu'  Hap  ami  I'l-cslicii 
up  the  margins  nf  llic  api'rtura  ]>>  rirmini-  sn  as  tn  nlitaiu  ]iriipcr  uiiinii. 

17.  |-;\poso  till'  ru>]  III'  till'  tiaiisplantril  Imni'  sliver  and  eventu- 
ally iVaetiire  it  so  as  tu  make  a  lip  nf  llie  imsi'. 

1^.  FreshiMi  up  an  area  nl'  lln'  Imur  at  iIh'  llnnr  nl'  the  nose  just 
in  iVnni  and  suturi'  in  this  free  end  n\'  thi'  Imhh'  •~li\ri-. 

1!t.      ('o\'er  this  liy  the  ui'\\l>'  I'lH'ini'd  cnl  unii'lla. 

111).  Turn  in  the  redunaut  skin  llap  at  tlir  alar  rei;iou  to  line  the 
uewlyd'oi'nu'd  nostrils  and  put  in  two  small  ruhhei-  tultes. 

ill.  K'ead.just  the  shnuhler  flap  and  eii\er  the  newly-fonned  bono 
det'eet  with  it  as  nearly  as  pnssilile:  what  rnnaius  may  ho  covorod 
with  skin  lirat't  or  allowed  to  Lirannlate. 

'2'2.     Snl)so<iuent  eoi-rertiim  on  the  nnsi-  may  1k'  ueeessary. 

VII.     Implantation  Method. 

Aside  iVom  the  very  popidar  and  sureessTul  method  of  iu.jeetini;" 
paraffin,  many  \arieties  of  iniiilantatinn  operations  were  formerly  per- 
formed for  the  corroetion  of  defects  or  nialforuuitions.  (lold,  German 
silver,  filigree  wire,  hard  rubboi-,  ete.,  have  been  nenerallv  abaiulonod 
for  newer  and  better  methods,  inasmuch  as  these  foreign  bodies  very 
frequently,  after  hoalinii-  in  beautifully,  became  the  seat  of  irritation 
whieh  neeessitated  their  ifniiixal.  The  iuiplautatiou  of  a  sliver  of  the 
anteriiir  hnnler  nf  lhi>  tilna  was  successful  in  one  case  of  the  author's; 
in  aiinthrr  it  lieranii'  iicemtie  and  rrninxal  \\a-  iiMpii  red.  Snin  nn- 
])lo\ed  deealcilieil  bone  chips  in  >onie  casi'S  of  saddlehack  luisv.  lie- 
cently  tlie  author  removed  a  sejitum  by  submucous  resection,  allowinj>: 
one  layer  of  ])oricliondriuni  to  he  attached  and  placed  it  in  a  dissected 

pocket  of  a  saddh'liack   imse  nf  ; ther  |ialien1.     This   healed  in  very 

lieautifnily  and   resulted  in  success. 

In  aiH)ther  case  three  different  im|ihintaliiin>  were  made  into  col- 
lapsed ahe  whii-li   liealrd   in.  Init   appearrd  In  lia\e  iu'mnie  •disiirlnd. 

.\nnlhrr  iih'tlind  aihnrali'd  iverntly  is  tn  implant  a  nia>-  nf  fat 
frnm  a  patient  iipnn  w  Imni  a  lapaintnmy  is  peil'nrmi'd.  intn  a  dis- 
sected jiockct  nf  a  saddleliack  nnse.  The  authnr  ha-  tried  this  methnd 
in  one  case  and  it  ap|)ears  that  the  fat  tissue  remains  alive.  The  niii' 
dilTiciilty  is  that  the  nose  looks  very  larne  foi-  a  time  as  a  ureal  amount 
of  fat  is  used  to  fill  up  the  defect,  in  oiiler  to  antieipali'  the  ali-nrptinu 
or  shrinkaue  of  the  mass. 


338 


Ol'EIiATIVK    SUIUiKItY    OF   THE    KOSE,    THIIOAT,    AND    EAK. 


'I'lie  cniviloyment  nf  a  sliver  nt'  hniic  tVoiii  tlic  aiitcrioi'  Ixirdcf  of 
tile  libia  or  a  part  of  a  I'il)  is  a  mctliod  that  lias  many  advocatos. 

Israel's  Operation  for  Saddle-back  Nose. 

1.  Make  an  external  incision  2  cm.  lorn;-  over  tlie  saddle  and 
dissect  to  all  sides  subcutaneously,  until  by  pulling  on  the  tip  of  nose 
the  appearance  is  normal.     Close  this  external  incision. 

2.  A  piece  of  bone  3  em.  long  from  anterior  border  of  tibia  is 
chiseled  off  and  formed  into  sharp  points  on  either  end. 

3.  From  the  interior  of  the  nose  the  previously  dissected  tunnel 
is  found  by  means  of  a  dissection  and  the  sliver  of  bone  is  introduced 
in  this  direction,  the  upper  end  of  the  bone  fragment  coming  in  contact 


Fig.  :il5. 
Israel 's  operation  for  saddle-back  nose. 

with  the  nasal  bones,  the  lower  at  the  tij^  between  the  external  skin 
and  tlie  lining  of  the  vestibule.     (Fig.  315.) 

Goodale's  Operation  for  Depressed  Nose.     (Fig.  316.) 
Modified  by  Watson-Williams. 

1.  The  mucoperichondrium  is  dissected  over  the  entire  cartilag- 
inous area  on  both  sides  and  ]iushed  up  and  back. 

2.  Loosen  up  the  tissue  below  the  depression  intranasally. 

3.  Cut  out  a  flap  of  cartilage  with  its  loosely  adherent  pedicle 
towards  the  depression.    (Fig.  317.) 

4.  Slide  this  cartilage  flap  below  the  depression  and  bring  down 
the  mucoperichondrium  into  its  original  position.     (Fig.  318.) 


PLASTIC    SmOERY    OF    THE    XOSE    nXD    EAR. 


339 


Fig.  310. 


i''g-  ^is-  Fig.  ;ii;i. 

Goodale's   operation    for   depressed    nose. 


340 


OPKRATIVE    srtUiERY    OF    THE    XOSE,   THROAT.    AND    EAR. 


5.     Hold  hy  transfixing  gold-i)lated  pins  for  tliicc  weeks. 
Tile  writer  suggests  silk  worm  gnt  suture  tied  o\er  rubber  tubing- 
or  gauze.     (Fig.  319.) 

Ouston's  Operation  for  Depressed  Nose  Below  the  Bridge. 

1.     Separate  the  eartihigiuous  |)orti<ui  of  the  (le[iresse(l  nose  sub- 
entaneouslv  from  the  nasal  bones  and  nasal  ])rocess  of  su])erior  maxilla 


mm 


Fig.  321. 
Ouston's  i)|j('i;itioii   for  lU'pressed  nose  liclow  the  luiilijc. 

on  either  side;  also  sever  the  cartilaginous  septum,  the  incision  being- 
made  latterly  lengthwise. 

2.  Transfix  all  these  cartilaginous  structures  with  one  of  (Juston's 
needles  (Fig.  320),  just  below  the  nasal  bones. 

3.  Pass  another  needle  through  the  nasal  bones  which  serve  to 
sup])ort  and  lift  the  loosened  eartilaiiinous  portion  of  the  nose. 

4.  Wind  a  thread  or  gauze  in  the  form  of  a  figure  eight  (8) 
fr(nn  the  upper  to  the  lower  needle  while  the  loosened  cartilaginous 
])ortion  of  the  nose  is  held  up.     (Fig.  321.) 


iM.ASTK'  sri;i;i'.i;v  nr  'I'lii:   nosk  and  i'.ak. 


:u\ 


Carter  s  Operation  for  Saddle-back  Nose. 

1.  r.\  iiic.nis  cpf  ;i  Inrnc  curved  needle,  wliieli  is  llire.ided  uitli 
Xn.  14  >ilk.  one  i<\'  llie  liai'd  niMiei-  siilints  is  ;inelinred.     (  l-'i--.  ;:•_'•_•.) 

■_'.  i';i>^  the  needle  tViun  witliin  untwnrd  al  tlie  Jnnelinn  cif  (he 
cartilaj^o  and  nasal  iione,  jnst  at  tiie  middle  of  llu'  dorsum.     (Fi.y;.  '■'>'2'.'>.) 

.").     Kepeat  tlie  first  step  on  tlie  other  side  of  the  nose.     (  Fiu'.  '.V2'.'i.} 

\.  AppJN  the  metal  ( ( 'aitei'- 1  hiid^e  and  set  it  liy  means  <if 
the  thmiili  >cre\\  >o  llial  it  lits  lirndy  at  the  ha.se  of  the  nn-,..     i  l-'in-.  :':2-i.) 


X^^ 


Fig.  32:i. 


Fig.  .124. 


«M<1.tl.-  l.nr-k     nn 


342 


OrERATIVE   SURGERY  OF   THE   NOSE,   THROAT,   AXD   EAR. 


.').  Draw  fii'mly  upward  on  the  two  threads  so  as  to  raise  the 
Hat  or  (h>pressed  nose  and  tie  thoni  over  the  hinge  of  the  bridge. 
(Fig.  324.) 

If  the  tissues  are  fixed  or  if  it  is  impossible  to  lift  the  nose  by 
the  threads,  it  may  be  necessary  to  loosen  the  nasal  bones  from  the 
nasal  process  of  the  superior  maxilla  by  means  of  chisels  and  forceps 
and  then  by  fracturing.  The  septum  of  the  nose  may  at  times  be  so 
short  as  to  necessitate  incision.  This  treatment  is  best  carried  out 
with  the  patient  in  the  recumbent  position,  but  by  employing  adhesive 


Fig.  326. 
Carter's   operation   fur   smltlle-back   nose. 


plaster  the  bridge  may  be  fastened  to  the  forehead  and  then  the  patient 
may  be  allowed  to  walk  or  sit  up.  This  bridge  is  allowed  to  remain  in 
position  from  ten  days  to  two  weeks.  Cleansing  the  interior  of  the  nose 
witli  Dobell  spray  is  advised. 


Carter's  Operation  for  Saddle-back  Nose  (No.  2). 

1.  Make  a  curvilinear  incision  to  the  periostemn  from  one  eye- 
brow to  the  other,  with  convexity  of  the  incision  downward.    (Fig.  325.) 

2.  Lift  the  skin  flap  and  make  transverse  incision  through  the 
periosteum  into  the  bone. 

3.  Elevate  the  periosteum  uiiwards  for  three-eighths  of  an  inch. 


PLASTIC    SrUCEUY    OK   TIIK    XOSK    AND    EAR.  34.'i 

4.  Kli'vntc  till'  skill  jiinl  sulK'ntaiit'iuis  lissnc  (ivcr  tin'  ilorsuiii  of 
the  nose  and  sidr  of  ihc  fhccks  as  far  as  tln'  clrlnnuily  I'xists. 

').  Ki'iiiiivc  ;i  <\\\\i  111'  ill!'  iiliitli  rill,  with  )ii'i-inst('iiin,  aliout  t\vi> 
iiU'lu'S  \ouiX  and  split  it  ti  aiisxtTsidy  sn  as  to  sliapo  it  to  correct  the 
deformity. 

6.  ScTa|ic  till'  caiUTlliius  tissiir  nlT  tlu'  lnuii'. 

7.  W'itliiiiit  i-riiiii\iiii;-  till'  liliiiid  riiiiii  till'  |iii'|.ari'il  |Hifki't,  insrrt 
the  lK)ni'  .ural't  as  far  dnw  ii  tlir  tip  of  the  iiosl'  as  nrcosarx'  and  plai-r  the 
upper  end  well  undrr  tlii'  ju'riosteal  flap.     (Fig.  326.) 

8.  Oiisr  till'  skill   llap  with  lini-sc  liair  sutures. 

9.  Apply  cnlliidiiiii  dri'ssiiii;'. 

Beck's  Method  for  Saddle-back  Nose. 

1.  Lift  up  tip  III'  till'  iiiisi'  and  niakr  a  small  srmicircuhir  incision 
In  the  anterolateral  pnitinii  nl'  the  \  est  ilmle  at  the  niucoontaneons  june- 
tiiin  of  the  cartila.t;''  and  Imne. 

L'.  With  ^layo's  seissors  dissert  ii\er  the  hniiip  as  in  l-'it;'.  'A2C}. 
A\'ith  the  same  scissors  eniia,uc  and  sexer  the  linnip  which  is  usually 
made  up  of  cartilaije. 

3.  Employ  a  i)ortion  nf  the  rili,  the  anterini-  surface  of  tiie  tiliia, 
or  a  iiortiou  of  the  se|»tal  ridize.  rrniii  the  patient  himself  or  from  an- 
iitiier  patient  w  im  has  Jii>1  lieen  ii]ii'rated  mi  I'm-  snliiiiueous  resection. 
The  size  of  the  Imne  splinter  slimild  (■m-respond  lu  the  si/e  and  shape 
of  the  deformity  to  he  eoireeted. 

4.  The  Mood  ex]ii-essed  fi'oni  the  ea\ily  is  mopped  awav  and 
an  adliesi\-e  plaster  is  drawn  ti.yhtly  o\ei-  the  hrid-e  of  the  nose  with  no 
dressing  between  it  and  the  skin. 

5.  One  silk  stitch  closes  the  wound. 

■Walshaus'  Operation  for  Collapsed  Alae. 

1.  }ilake  a  llaji  of  the  iiiiieniis  meiiihraiie  of  the  most  anlei'ior 
poi'lioii  of  septniii,  one-i'iiiht  h  of  an  iin-li  wide  and  luie-lialt'  of  an  inch 
liinu',   leaxdiii:-  the  liediele  al    the  ilorMim   of  tile  liosi'.      (Fig.  ol27.) 

■J.  U'oll  np  this  miieiiu>  inemlirane  llap  and  fasten  in  the  upper 
aiii^le  ol'  the  nostril.     (Fig.  327.) 

.'1.      lii'|)eaf  the  same  on  the  opposite  no-tril. 

Lambert  Lack's  Operation  for  Collapsed  Alae. 

1.  l\i'mo\e  a  strip  of  miieoii^  nieiiiln-ane  from  the  right  side  of 
the  most  anterior  poitimi  nf  the  >epliiiii.  measuring  alxiut  one-eighth 
inch  w  ide  and  mie  half  ineli   hum. 

'2.  (  ut  thi-oii,uli  the  cartilage  and  miienns  inemlirane  into  the  left 
nostril  corresiionding  to  the  defect,  lea\inL;,  hiiwe\er,  the  llap  intact 
at  its  liiiiiie  ])edicle  at  the  dorsnin  of  nose. 


344  OFKRATIVE    SrilGEKY    OK   THK    XOSE,    THROAT,    AXD   EAR. 

:!.  Dcmulc  the  surface  of  its  mucous  nieuiln'auc  where  the  septum 
and  lateral  cartilage  of  ahi  come  too-ether;  also  of  the  denual  layer  of 
the  iiiuci-  side  (if  the  ala. 

4.  Turn  the  cartilage  niucuus  membrane  Hap  u\)  in  the  right  nos- 
tril plaeiui;-  the  two  denuded  surfaces  together. 

.").  Make  a  similar  flap  back  of  this  one,  only  reversing  the  denu- 
dation on  the  septum. 

().  Tuni  this  flap  into  the  left  side  and  tix  to  a  similarlx  dcnndcd 
surface  of  the  ala,  only  further  back.     (Fig.  328.) 


Kg.   327.  Fig.   32S. 

AValsliiius'    opoiation    for    collapsed    alse. 

Paraffin  Injections  in  Nose  and  Ear  Deformities. 

The  history  of  this  means  of  correcting  nose  and  ear  deformities 
•dates  back  to  1900,  when  Gersuny  corrected  a  saddle-back  nose  by  the 
use  of  melted  vaselin,  injecting  it  below  the  skin.  Eckstein  in  1901 
employed  hard  paraffin  which  has  a  melting  point  of  140°  F.  for  similar 
defects,  and  claimed  for  it  superiority  in  that  there  was  less  chance  for 
pulmonary  embolism.  This  method  was  very  warmly  received  and 
employed  by  Broeckaert,  Brindel,  Karenski,  Lake,  and  others  abroad 
and  by  Harmon  Smith,  Kolle,  Quinlin  and  otliers  in  the  United  States. 

The  principal  indication  for  paraffin  injection  is  deficiency  of  tis- 
sue about  the  nose  or  ears,  since  excessive  growth  or  absence  of  tissues 
of  the  external  nose  and  ears  are  not  within  the  limits  of  this  method  of 
treatment.  Frequently  there  are  ])ost-traumatic  or  inflammatoiy  con- 
ditions about  the  nose  which  leave  scars  and  adhesions  that  will  pro- 
\cnt  proper  injection  of  paraffin.  In  such  cases,  pr-eliminary  dissec- 
tion or  loosening  of  these  scars  may  be  necessary.  The  introduction 
of  a  small  quantity  of  paraffin  after  such  dissection  to  keep  the  skin 
from  readhering  is  good  practice.    Subsequently  one  may  complete  the 


n.Asiic  sri;»;i;m    m     riii.    nosi.   anh   i;.\i:.  .">)"i 

in.ji'ctioii  in  niic  nr  iihui'  sittiiii;>-     N<>  niii'stliftic  is  I'ctiuircd  cxcriil   in 
yoiiiiu:  iiuliviiliiJils  who  wdulil  imt  iciiuiiii  quii't  diiriiii;  tlic  iiijcc'tiini. 

Miiiiy  uiitowanl  ivsults  liavi-  liccii  rt'iiorti'il  t'linn  the  use  of  paralliii 
iii.jci'lioii  ami  affonliiii;-  to  ("oiiiU'U,  who  lias  uathcrcil  Ihi'in  iVoiii  the 
litciaturo,  they  may  Itc  irroupod  as  I'ollows: 

1.  Td.ric  (ihsorpiinii  ny  iuloxudlinu. —  'i"hi>  ciiiiililiiiii  is  most 
]piolialily  ihic  to  the  impurities  in  the  paralliii  and  not  to  the  chcinica! 
alisorplion  aini  rcaotioii  of  the  paralliii  itscll'.  Too  iaru'c  a  quantity, 
alioiit  1  111  ot'  thf  liody  wcij^ht,  would  iia\c  to  lu-  iiijcctfd  iirfoic  an> 
l(i\ic  symptoms  would  ho  ohsorvcd.  arcordinu  to  .TuJcnlT. 

'1.  I iilliimiiKifiiri/  reaction  when  Ihr  propci-  tcchnic  has  not  iircn 
carried  out,  in  iii.jectius;'  too  lariie  a  (piantity  of  paralliii  at  one  linic 
or  if  the  material  contains  any  impurities. 

'.].  Loss  of  tissHi  dur  to  inri'ction  and  secoinlary  aiisccss  forma- 
tion has  been  observed  to  r<illow  these  injections  when  tin'  usual  asi-p- 
tic  precautious  which  are  expected  to  he  carried  out  in  any  sur^ieal 
o]i(>ration  hav(>  not  hiM'ii  ohserxed.  Instninienls,  the  lield  of  operation, 
aiiil  the  material  itself  inu>t  all  he  sterile.  The  -kin  oITits  the  irreal 
est  dil'lieulty,  since  ther<'  are  constantly  n:any  \arieties  of  microiirt^'an- 
isms  about  the  nose,  ahe  and  vestihule.  which  are  loi'uted  in  and  incor 
porated  with  the  sehum  in  the  jilands.  and  are  \  i-iy  hard  lo  eiadi<'a1e. 
However,  since  linctnre  of  iodiii  has  heeii  eniploye(|  hcfore  operation 
for  paintiiii;  the  area  even  withmit  pi-e\  iously  uhui;-  any  soap  or  water, 
there  i>  less  cluuice  fur  infection  after  these  injections. 

4.  Pressure  necrosis  will  invaiiahly  follow  when  tlie  paraffin  is 
injected  into  the  skin  pirojier  latlier  than  suhcutaneously.  It  will  also 
follow  w  hell  too  i.;reat  a  i|iiaiitity  is  iiijerlrd  at  one  time  hy  shnttin.;;'  olT 
the  hlood  supply,  with  a  uicater  ehaiiee  for  secondary  infection.  A.yain,' 
it  is  essential  to  he  nio-1  ean^fnl  if  there  exists  some  constitutional  dis- 
tiiriiance  m-  local  (le\itali/.at ion  of  the  tissues,  such  as  re-iilt-  from  scar 
tissue,  firmly  lioimd  down  skin  must  always  be  lirst  liln'iated  before 
tile  inject  ion  of  paraffin. 

.").  Shiidiliiiifi  has  been  reporteil.  especially  when  the  paraflin  w;is 
injected  while  \-ery  hot.  'file  author  a.iii'ees  with  many  operators  thai 
this  is  very  unlikely,  because  by  tin'  time  the  paraflin  is  injected  into 
the  tissue  it  has  cooled  olT  to  a  deuiee  approximatinn-  the  body  tempera- 
ture. Since  the  hard  parallins  ( lOckstein  14(f)  are  now  employed, 
complication  from  this  cause  seldom  occurs.  Sloii.i,diiu.si:,  however,  does 
occur  when  the  injection  is  made  into  the  w  roiii;  pla<-e.  as  into  the 
skin  especially  where  it  is  lirmly  hound  down  nalnrally  or  by  scars. 
This  complication  may  be  a\diiled  hy  fust  makiii!,'-  a  siihciitaiieous  in- 
jection of  -terile  oi-  iiormai  salt  solution  or  h\-  the  subcutaneous  dissec- 


34()  OPEr>ATIVE    SURGEKY   OF   THE    XOSE,    THROAT,    AXD   EAR. 

tion  and  an  injection  of  three-fourths  vaselin  and  one-fourth  ]iaraffin 
so  as  to  ])revent  roadherenee  of  the  dissected  surface.  An  incision 
sliould  be  made  and  plates  of  ])aratifin  or  Cargile  membrane  introduced. 
Then  injections  are  made  small  in  quantity  until  the  deformity  is  cor- 
rected. It  is  well  to  observe  the  general  condition  of  the  ]iatient  and 
in  syphilitic  cases  a  Wassermann  reaction  should  always  precede  the 
injections  to  be  sure  that  the  blood  is  in  good  condition,  even  when  the 
l)atient  shows  no  active  symptoms. 

6.  Suhinjection  or  the  injection  of  an  insuflicient  (piantity  can 
scarcely  be  classed  as  an  untoward  result;  it  is  only  necessary  to  inject 
again.  If  subinjections  Avere  common,  less  disagreeable  results  would 
be  reported. 

7.  Hyperhijecfiou  or  the  injection  of  too  great  an  amount  occa- 
sions the  most  disagreeable  results  met  with  in  this  procedure.  This 
is  especially  true  when  this  mass  undei'goes  early  organization.  Under 
these  circumstances  its  removal  by  surgical  measures  is  required,  since 
the  various  solvents,  as  ether,  xylol,  benzine,  chloroform  and  heat  have 
very  little  efifect.  Electrolysis,  the  negative  pole  being  introduced  into 
the  mass,  has  been  suggested  as  beneficial,  but  the  author  has  found 
it  of  no  value  in  a  case  of  paraffinoma  so-called,  in  which  he  employed 
this  method.  Instead  of  making  external  incisions  the  vestibule  may 
be  opened.  It  is  well  to  remove  the  excess  of  paraffin  just  as  soon 
as  possible  before  organization  has  taken  place. 

8.  Air  emholisin  may  occur,  especially  wlien  cold  ])araffin  is  em- 
IDloyed.  In  filling  the  syringe,  the  needle  is  as  a  rule  obstructed  and  an 
air  chamber  remains  between  it  and  the  paraffin  taken  from  the  glass 
tube.  This  should  be  avoided  by  completely  emjjtying  the  syringe  and 
needle  before  refilling  and  then  forcing  out  fresh  paraffin  through  the 
end  of  the  syringe.  If  a  small  air  bubl)le  gets  in  lielow  the  skin  it  will 
do  very  little  harm. 

9.  Paraffin  eiiiholisin  is  of  a  more  serious  nature.  In  fact,  it  nmst 
be  named  as  the  most  dangerous  accident  in  connection  with  paraffin 
injections.  There  are  several  reports  of  death  from  this  cause  and 
many  grave  symptoms,  as  blindness,  pneumonia  and  cerebral  embol- 
ism, have  been  recorded.  If  the  needle  is  introduced  below  the  skin 
separately  from  the  syringe  and  no  blood  allowed  to  escape  then  the 
immediate  danger  of  embolism  following  the  fragmentation  of  the 
paraffin  is  obviated.  It  is  thought  that  these  small  particles  getting 
into  the  circulation  caiase  the  trouble,  but  the  explanation  is  more  the- 
oretic than  real.  After  eight  years  of  personal  experience  with  paraffin 
in  various  methods  and  locations  in  a  goodlv   iiundier  of  cases,  the 


PLASTIC    SIUC.KKY    OK    TIIK     NIISK    AND    KAlt.  ;J4  ( 

author  cannot  report  a  sinii^lc  iiislam-c  or  even  a  s\iii|iloiii  ri'lVralilr  lo 
parallin  ('inl)olisni. 

Ill,      I'liiiiiiiii  ililfiisinii   or  I'.ih-ttsinti   nt    paiiiHin    will  occur  cspc- 

,-i;ill\    nlti-r   iiiJiM-tiiin-   I'or   the   coi-rci'I'hin    of  a    -addle  iiaek  nose,    when 

th,.   11,.,'ilii'   piiilll    i>  allowed    to   -o   lieMUld    the    liiiiil-   ..r  after   illjeelillU-   a 

laiiier  aiiiMUiit  than  one  shnidd.  ainl  e>pi'ciall\  w  lirn  nsinu  li'iiiid  i  hot  ) 
]iai-ariin  or  \a>elin.  The  liio>c  areolar  ti->iie>  of  the  IoWit  lid,  eherk- 
and  oychrows  arc  the  pi-iiieipai  location  for  dil'fn>ion  of  the  parallin. 
By  having- the  assistant  liold  his  tinu-ci-s  liniil>  down  on  the  hony  struc- 
ture over  tile  root  of  the  nose,  as  well  a-  ;it  il>  si<ii',  a  t:ieat  deal  of  this 
danger  will  he  axoided.  Semi  soliil  or  eold  p.aianin  praetiejilly  uiakos 
this  accident  inipossilile.  The  author  taki's  a  piece  of  dental  inodelinij: 
compound  and  while  warm  and  soft,  molds  it  lo  lit  the  almve  Mameij 
maru-ins  at  which  the  assistant  holds  his  linLivi-s.  This  in>ures  abso- 
lutely the  retention  of  the  paral'lin  within  the  limit-  of  this  mold,  which 
when  it  cools  becomes  \cry   hard. 

1  1.  hiferfcri'iirc  irilli  lltr  drlnoi  -W  Ihr  nmsdc  -//  ///,  nl,,  n,  iint(i.< 
<il  Ihr  iitjsr. — This  is  most  likelv  lo  happen  wiien  a  \-er>  low  deformity 
of  the  nose  is  to  he  eoi-|-crti'd.  The  aiithm-  ha>  loiind  that  iheopposim;- 
mnsclos  of  the  constrietor>  of  the  ahe  eaninM  a.-t  and  th.'  patient  then 
comiilains  of  nasal  obstru<-tion  like  that  due  to  paial\sis  of  the  dilating- 
or  lifting-  muscle  of  the  winus  of  the  no-e.  In  oidei-  lo  prevent  the 
paraffin  from  coming  down  too  t'ar  a  hnger  should  he  inserted  into 
the  nostril  during  the  injection  and  the  tiji  of  the  nose  raised  upward 
and  outward,  if  a  latei-al  in.jeclicm  is  madi'. 

12.  Escape  of  iimolfni  after  injection  can  he  axdided  by  thor- 
oughly mokling  the  mass  into  ihe  desired  shaiie.  although  this  should 
be  done  even  while  the  nee.lle  is  still  within  Ihe  tissues  so  as  not   to 

get  the  mass  into  one  place.     The  n lie  >h.>iil.l  he  moved  ahonl.  almost 

withdrawn,  and  ivint  rodnceck  >iiice  the  paiaflin  oflen  >ticks  to  the 
needle.  The  neiMlh^  siiould  he  witlidrawn  only  after  no  more  jiarallin 
whatever  is  escaping  fi-om  il.  It  escapes  usually  for  a  few  moments 
even  after  the  turning  of  the  piston  ceases  on  aceomit  of  tiie  pressure 
within  the  syringe.  A  fine  blunt  ]ioiiited  probe  shouhl  he  jiassed 
through  the  o]K'ning  of  the  skin  so  as  to  l)e  sure  that  no  paraflin  is  left 
in  the  skin  puncture.  A  .Irop  of  collodion  will  further  close  the  punc- 
ture and  pri'Venl  the  escajie  of  any  paiaflin.  .\a>al  moliou  or  manipu- 
lation should  be  prevented.  If  lii|uid  paralVm  is  employed  un<ler  such 
circumstances  cold  applications  foi-  a  few  moments  are  advisabh'. 

13.  SnVtfJifirntion  fif  the  pniaffiti  in  the  syringe,  or  more  fre 
quently  williin  the  needle,  is  a  condition  that   complicates  the  technic 


348  Ol'KHATINl'.    SIKIIKin'    Ol'    'rHK    XOSi:,    TIIKdAT,    AMI    V..\i\. 

very  luufli.  i'S]H'ci;ill>'  wlicii  iijirjil'liii  nf  liii;li  niclliiiii-  pdini  is  used.  The 
injection  iiiiist  l)c  nccoinplislicil  (|uickiy,  ri-c(|uciitly  iifccssitaliii^'  llii' 
licatiii.n'  of  the  needle  o\'er  a  IhiiiH'  .just  liel'oi-e  itit roihietioii — a  in'ocess 
which  may  lie  injurious  to  the  skiu.  Ai^'ain  the  sudden  exjiulBion  of  the 
lii|uid  pai'affin  into  the  tissues  may  cause  it  to  ])ass  into  undesirable 
locations  <m-  too  nmcii  jtaraffin  may  be  injected  at  one  time,  eausini^'  all 
tlie  comjilieatious  of  hyijei'injections.  The  fact  thai  semi-solid  par- 
affins in  the  cold  state  are  mainly  employed  uow,  uiakes  this  occurrence 
rare.  It  appears  to  the  author  that  when  the  same  syringe  that  is  em- 
jiloyed  for  the  semi-solid  jiaraffin  is  used,  however,  with  a  very  short 
and  conical  needle,  the  solidification  of  the  paraffin  is  obviat<'d.  By 
rapidly  screwing'  the  piston  down,  the  injection  can  he  more  rea<lily 
controlled. 

14.  Abs<)r[Ah)ii  and  (llshitvuriitioii  of  the  parafhn  injected  are  of 
considerable  interest  and  importance.  Some  authors  believe  that  the 
injected  mass  becomes  encapsulated  by  a  fibrous  capsule  like  a  foreign 
body,  Avhile  many  others  with  histologically  examined  tissue  as  proof, 
believe  that  the  mass  is  first  surrounded  with  a  connective  tissue  wall, 
and  that  fibrous  bands  traverse  the  mass  and  subdivide  it.  The  par- 
affin finally  becomes  absorbed  and  all  that  is  left  is  a  new  connective 
tissue  mass  of  cartilage-like  consistency  to  the  touch.  The  ultimate 
absorption  of  the  ]jaraffiii  does  not  seem  to  have  any  effect  on  the  gen- 
eral condition  of  tlie  individual.  The  time  required  for  the  paraffin  to 
become  absorlied  vai'ies  according  to  the  kind  of  paraffin  injected,  the 
amount  and  location  of  the  injection,  and  differs  even  in  different  indi- 
viduals. Some  authors  have  found  that  after  one  month  a  good-sized 
mass  was  entirely  replaced  by  connective  tissue,  while  others  have 
found  paraffin  as  late  as  four  months  after  injection.  The  harder  the 
paraffin  the  longer  will  it  remain  and  the  less  will  it  be  traversed  by 
connective  tissue.  In  loose  connective  tissue  areas  absorj^tion  will  be 
more  rajiid  tlian  in  closely  bound  down  areas.  Small  ([uantities  in- 
jected at  a  time  will  l)e  absorbed  more  i-ajiidly  than  larger.  It  is  of  in- 
tei'est  to  note  the  action  of  the  newly-formed  connective  tissue  as  to 
absorjition  and  contraction  on  taking  on  neoplastic  manifestations. 

15.  Difficidties  as  to  tlie  proper  nielt'nui  point  of  tlie  paraffin. — 
In  this  regard  widely  different  opinions  are  exjiressed.  However,  the 
great  number  of  ojierators  believe  tliat  paraffins  of  lower  degrees, 
melting  point  from  1)7"  to  115°  F.,  are  the  best  for  the  purpose.  The 
author  believes  that  the  formula  recommended  by   i\olle: 

Paiaffiii    ( iilat(>  sterile) 3ii 

Vaselin    (xvliitc   sterile) 3ii 


I'l.ASTIC    SriKiKltV    or    TIIK    XOSK    ANII    KAK.  ''iV.) 

is  tlic  Iti'st  to  I'liiploy.  (Mass  lulics  iiiay  l>i'  prcpart'd  stfrili-  in  ail\aiici' 
and  ill  llii'st'  tlic  i»aial1iii  may  he  it'stfriiizcd,  tube  and  all,  just  licfori' 
the  in.jt'c'tiiui.  li\  wasliin.u;  witli  hicldoricl  and  alcohol.  Tin-  injections 
slionltl  Ite  made  with  this  semi-solid  itaiallin  in  a  cold  stale  ln-eause  the 
eomiilications  anil  nnplcasant  resnlls  may  thus  hr  avuidnl. 

1(1.  Uifiicrsiiisilirriu'ss  of  tiie  skin  jilays  a  \ery  small  roh-  in  the 
objections  or  diniculties  met  witii  in  tiic  use  of  iiaraHin  injections. 
Usually  for  a  short  time  oidy,  twenty  four  to  forty  eii;lil  hours  after 
the  injection  is  maile,  is  tiiere  any  complaint  of  pain.  More  often 
patients  c<im]ilain  of  a  sense  ol'  distension  or  of  a  drawn  feelimi'.  iialc 
symjitonis  rarely  de\el(i]i  if  cold  paralliii  i>  used  in  small  amounts  at 
a  time  and  if  >ciiMe  liitle  lime  in1er\-eni'-  ln'lweeii  tile  injeetiiins.  Har- 
mon Smith  reports  a  sense  of  numimess  following;-  tiie  injection  and 
otlier  authors  have  reported  sul)se(|iu'nt  nenralyie  ])aiiis  from  the 
sensory  nerve  filaments  caught  in  the  newly  furmeil  connective  tissue 
mass  after  the  ])aral1in  has  liecome  ahsoi-bed.  If  infections  of  the  skin 
or  subcutaneous  tissue  sliniijd  t;il<e  p|;ici-  fullowin.i:;  the  injeetiim.  there 
may  be  some  tenderness  or  liypiTsen-ii  ixcui.ss  of  the  area  injeeied. 

17.  Redness  of  the  skin  is  a  prett>'  constant  result  of  paraflin  in 
jections.  Tt  \aries  a  ureat  <leal  in  decree,  thei'e  being'  in  some  cases 
only  a  llusli,  while  in  otlieis  a  vcyy  de<-])  red  ctAov  follows.  Ai^ain  it 
may  simulali^  a  ura\i'  •.[(■t\i'  in-;ieea,  with  distinct  new  Mood  vessel 
(ca])illary)  foiination.  Ii  may  aUo  appear  at  dillVrent  times  follow- 
ing; the  injection.  Sonietinio  immediately  alter  the  injection  has  been 
made,  es])ecially  if  hot  liipiid  paraffin  is  emploxi'd,  the  nose  becomes 
very  red  and  it  may  eontinm'  so  for  a  Ioiil;-  lime,  .\iiain.  the  redness 
and   capillary    fo|-niation    may    not    oeeiii'   until    months   later.      This   a|)- 

])e;il->   to   lie   dlH'   |o    1 1  \  pi  ■  I'i  11  Ject  i  oUS.   opeciailv   of   hot    material. 

Keilness  is  un(|ue^t  ionalily  due  io  pres>ni'e,  on  the  \-ennle>  such  as 
one  would  olitain  in  l>iei's  iiyperemia,  and  possibly  to  iin  active 
hyjieremia.  nature's  part  to  assist  in  absorliiiii;-  the  t'oreig"!!  body, 
liaraflin.  .\uain,  late  ap|iearauce  of  the  ie(liie>>  i>  \ery  likely  due  to 
cicati-ieial  >nlientaneoii>  coiil  i-ael  ioii>  from  llie  new  substitute  connec- 
tive tissue  ma-.-.  Wlieiher  the  chemical  action  of  the  hydrocarbons  has 
anythin.y  to  do  witii  the  redness  of  the  skin  has  not  yet  l)een  determined. 
The  early  evidence  of  redness  nia>  be  nliivcd  by  ice  cold  aiijilications, 
moist  dressings  of  acetate  of  ahiminnm.  idithyol  salve,  (en  ]»er  cent 
extract  of  eiuotol.  bi'lljidonna.  and  adicnalin  inteniall\ .  In  later  stages 
the  same  treatment  pln>  the  excntiial  >e\ciance  of  newly  I'ornieil  blood 
vessels,  pimcturim,'  of  the  skin  \ery  superliciall> ,  .•ind  electrolysis  have 
all  been  suggested.     Math'  cases  when  \ci'\-  stormv    and  I'cd.  max'  call 


350  OPEIIATIVE   SriUlEKY   OF  THE   NOSE,   THKOAT,   AXD   EAH. 

fur  iiMiKivjil  of  some  of  the  injected  mass  and  older  cases  after  all  has 
been  <U>ne,  may  require  the  dissection  of  some  of  the  newly  snl)stituted 
mass  of  connective  tissue.  The  author  has  found  that  a  certain  amount 
of  redness  follows  these  injections,  bnt  that  it  never  lasts  very  long 
and  eventually  disappears. 

18.  Secondary  diffusion  of  tlie  injected  paraffin  has  occurred  a 
number  of  times,  especially  into  the  loose  tissues  of  the  eyelids.  The 
difificulty  lies  in  the  fact  that  the  paraffin  is  injected  in  areas  tightly 
bound  down,  as  the  root  of  the  nose,  and  finding  a  lack  of  resistance  at 
this  place  it  migrates  into  the  looser  areas.  In  all  such  cases  tlie  use 
of  cold  paraffin  in  small  quantities  will  avoid  this  difficulty;  when  once 
diffusion  or  migration  has  taken  place,  excision  is  aixiut  all  that  can 
be  done. 

19.  lliijHipUtsid  of  the  connective  tissue  following  the  organiza- 
tion of  the  injected  matter  has  been  observed  a  number  of  times,  and 
the  author  had  a  very  pronounced  case  come  under  his  observation, 
which  is  here  illustrated  (see  Fig.  329).  The  specific  cause  of  such  new 
formation  of  connective  tissue  in  this  extensive  form  is  not  known,  and 
most  authors  believe  it  to  be  due  to  a  special  predisposition  on  the  part 
of  the  individual,  such  as  is  found  in  the  tendency  to  develop  keloids. 
When  such  a  disfiguring  condition  develops  there  is  only  one  procedure 
admissible — the  complete  excision  of  the  fibrous  mass.  If  there  should 
be  a  recurrence,  a  second  operation  must  be  performed. 

20.  Yellow  appearance  and  thickening  of  the  skin  after  these  in- 
jections are  observed  in  rare  instances,  and  they  are  among  the  most 
difficult  conditions  to  deal  with  satisfactorily.  The  cause  is  supposed 
to  be  the  use  of  hard  paraffin  injected  too  close  to  the  dermal  layer  in 
regions  where  there  is  not  enough  loose  underlying  tissue.  The  elec- 
trolytic treatment,  by  making  a  nnmber  of  punctures  at  repeated  sit- 
tings, is  advised.  This  Avill  bleach  the  area  by  secondary  scar  forma- 
tion and  contraction.  In  case  the  result  from  such  treatment  is  not 
satisfactory,  it  may  be  necessary  to  excise  the  pigmented  portions. 

21.  Breaking  down  of  tissue  and  resultant  abscesses  due  to  the 
pressure  of  the  injected  mass  upon  the  adjacent  tissue  after  the  injec- 
tion has  become  organized  have  been  observed  generally  in  cases  fol- 
lowing trauma.  Abscess  formation  has  been  observed  without  this 
cause,  and  may  be  due  to  the  increased  pressure  on  the  blood  vessels, 
causing  their  obliteration  and  the  breaking  down  of  the  tissues.  The 
treatment  consists  in  making  a  small  incision  and  draining  the  accumu- 
lated purulent  material.  When  all  reaction  sjmiptoms  disappear  the 
parts  are  again  injected. 


ri.Asric  sri;i;i;i;v  di'    iiii',   Nnsi-:  anh  i;ai:. 


:;:)i 


Technic  of  Paraffin  Injections.  I iisliKiiiints. — .\li"ui  all  tli.it  i- 
r('(|uin'il  is  a  syriiiu'c  which  is  strmi:^-  ami  not  Icui  lioavy,  with  a  siTrw  m 
ratclii't  anaiiiii'iiu'iit  I'tii'  cxiiri'ssiiij;'  the  |)aral1iii  slowly.  Imt  wliicli  can 
also  lie  made  to  cxiicl  its  coiili'iits  in  hcalcil  liipiiil  t'onii  in  a  <'ontinnous 

lliiw.  There  arc  iiian\  wiridirs  dii  the  m.-nkei.  ;iihl  tlmse  nf  llannnu 
Smith.  IJrceckaert.  I'lck'^lein.  KdHe,  nn.Mli.  \\;iII<it  Dnumaii  and  llic 
author's  arc  all  satisfactory.  The  onl\  dillicultv  willi  iiid-t  of  tlicni  is 
that  tli(\\'  arc  arraiii;cd  onl\'  I'or  the  use  of  si'iiii  ^-ulid  iiaialVm  c\- 
|)i'esseil  liy  ihc  screw  iuethod.  or  Uw  tlic  li(|nelied  Iml  iiaraffni  in  ;i 
continuous  flow.  The  aullinr's  syrin^i'  (  l''iu'.  ^l-'HM  is  so  conslructiMl  that 
it  may  be  adajitcd  for  citiier  \aiiety  of  parallin.  For  the  main  ideas 
in  the  construction  of  this  instrument,  the  aiiilmr  is  indchte.l  t<i  \'. 
^lucllor.  instrument  maker.  Chicago. 

Tlic  li'ri'at  advaiitai^'c  which  the  instiunieiit  n\'  liicieekaeit  lias  o\-cr 


^«  o 


■^=^n 


Beck 's  parnffin  syrinpc. 


others  is  that  it  can  he  manai;ed  by  the  operator  with  one  hand  while 
the  other  can  be  used  to  prevent  tlie  paraflin  from  oscai)in.t!:  into  the 

loose  tissues.     "Nforeovei'.  wlicn  one  is  injeclim:-  intranasally  the  otluM- 

hand    is    fl-ee   t(.   dilate   tile   I|n>l  ril. 

\'arious  shaped  needles  will  sm^uevt  theni-el\e^  f(ir  u-e  in  difl'er- 
eid  special  localities.  In  injectinns  ahniit  the  nose  a  needle  with  too 
lai^e  a  calihi'r  shonld  he  axdidi^d.  since  thi'  opi'nin.i^  will  prevent  hcal- 
ini;-:  in  fact,  there  is  -leater  liability  to  infection.  Ai^ain.  the  lileediiii; 
is  li'i'caler  from  the  -kin.  althouuh  it  i-  ni\ei-  df  anv  ureat  conseiinence. 

Miilrriiil.  I'araflin  which  has  a  meltiiii;  point  of  110°  F.,  with  the 
follow  inir  fdrmnia:  sterile  plate  ])araflin,  15,  .sterile  white  vaselin,  ]2(), 
is  made  up  and  lilleil  ini<i  -lass  tubes,  open  at  both  ends  and  havin.ij  an 
inner  dianieti^r  exactly  eipial  u>  lli;it  df  the  tube  in  the  syrin.tre  (0.5 
cm.).     The  ends  arc  coi-kci|,  and  the  cdik  >tdp)ier  is  ei.atcd  with  a  layer 


352  orF.nATivK  srr.cEnv  or  tiik  xosk.  tiihoat,  and  kak. 

of  paraffin.  Tlicse  tubes  are  always  ready  for  retiUiiii;'  the  syrins-e,  and 
all  that  is  necessary  is  to  wash  tliem  in  bichlorid  and  alcohol  before 
iisiiiii'. 

Fllliiu/  llic  Sjiinifir  (i.iliilr  Ihc  in  I'dir  is  at lialicti ) . — 'I'ui'n  the  rin.c," 
bar  so  thai  it  can  be  slipjicd  ddw  n,  thus  reh^asin^'  tiic  jiiston  screw. 
Pull  out  the  liandh'  of  the  syringe,  so  llint  tlie  ])ai'ariin  chamber  is 
opened.  Then  uncorkinii'  both  ends  of  a  ]ii-cpni(Ml  tube  ami  holdiiii^-  one 
end  rinbt  over  the  paraffin  chamber  of  the  syring'e,  the  paraffin  is 
jiusbcd  into  it  by  means  of  the  metal  roiL  It  should  be  noted  that  the 
end  where  the  needle  is  to  be  attached  is  to  be  free  from  paraffin;  other- 
wise the  air  thus  included  will  prevent  the  paraffin  from  filling-  tlie  en- 
tire chanil)er  of  the  syringe,  and  on  injecting,  some  air  will  enter  the 
tissues.  This  may  not  do  any  liarm,  Itut  may  elevate  the  tissues  and 
deceive  the  operator  as  to  the  amount  of  paraffin  injected. 

If  hot  liquid  paraffin  is  to  be  em])loye<l,  then  tlie  ring  bar  is  left 
down  and  the  paraffin  is  drawn  up  through  the  needle.  Instead  of  this 
procedure,  the  syringe  may  be  filled  first  and  the  needle  attached  after- 
wards. The  syringe  should  be  kept  in  very  warm  water  until  ready 
to  be  nseih  It  may,  however,  become  too  hot  and  uncomfortable  to 
liold,  and  for  this  reason  the  author  employs  heavy  rubber  gloves  when 
using  this  method. 

rrcparafin))  nf  Field. — lentil  two  years  ago,  thorough  scrubbing 
witli  soap  and  water,  bichlorid,  ether  and  alcohol,  was  the  iisual  routine 
before  injections,  but  since  then  the  author  simply  has  the  field 
scrubbed  with  alcohol,  following  which  he  applies  the  ten  per  cent  alco- 
holic solution  of  tincture  of  iodin. 

Paraffin  Injections  in  Nasal  Deficiencies. — The  skin  must  be 
sufficiently  loose  to  enable  one  to  raise  it.  If  through  contraction  of 
scar  tissue  or  otherwise  this  is  not  possible,  a  small  incision  must  first 
be  made  and  the  skin  dissected  loose.  If  tlie  resulting  incision  is  too 
large  and  there  is  danger  of  tlie  ])aralhii  exuding,  it  is  well  to  juit  in  a 
stitch. 

Injection. — Raise  the  skin  as  in  any  subcutaneous  injection  over 
the  site  to  be  injected,  and  thrust  the  needle,  apart  from  the  syringe, 
throngh  tlie  skin.  The  direetioii  of  tlie  needle  is  fi-oiii  the  root  of  the 
nose  downward.  As  a  rule  no  blood  conies  back  through  the  needle, 
but  if  this  should  occur,  draw  the  needle  slightly  outward  and  pass  in 
a  somewhat  different  direction.  In  order  to  prevent  the  cavity  filling 
with  blood  and  fonning  a  hematoma,  it  is  best  to  compress  the  parts 
for  a  few  moments,  before  injecting  the  paraffin.  Now  attach  the 
syringe  by  holding  the  needle  steady,  and  then  turn  the  handle  while 
holding  the  barrel  of  the  syringe  by  the  crossbars.  An  assistant  holds 
his  fingers  firmly  over  the  root  and  side  of  the  nose  so  as  to  prevent 


PLASTIC'  sn;i;r.i!Y  or  tiik  nosk  and  kah.  •■  i  ■ 

the  ]iaraftm  t'rdiii  timliiin-  its  way  into  tlic  loose  tissue  or  oilier  phuvs 
wliere  no  pai-allin  is  (K'sirf<l.  If  colfl  pai'allin  is  employed  lliis  is  not 
very  likrly  to  happen.  It  is  well  i  epentcilly  to  draw  tlie  imtiIIc  out- 
ward almost  to  tile  skin  openinu-  while  injeetiiii:-.  in  nrder  to  lilierale  it 
from  the  mass,  and  in  that  way  the  parallin  will  he  moie  uniriii'nd\- 
(listril)nted.  Ai!,-ain.  a  eeilain  amoniit  of  moldini;-  is  possihle  while  in- 
.iectiiiir,  and  this  may  he  aidiii  hy  iiTi.uatini'-  the  skin  with  very  warm 
water  or  hot  eonijiresses.  After  having;'  "iiveii  a  pro|ter  sha[)e  to  the 
injeeted  mass,  ice  applii'ation>  will  Taeilitate  its  solidilication  and  the 
retention  of  it>  shape.  The  -nvilot  r.ire  mn>t  he  exercised,  as  already 
pointe<l  ont,  not  to  inject  too  much  at  one  time;  it  is  lietter  to  repeat 
tlie  injection  a  nnmlier  of  times. 

1\\HAKKIN    In. I  ACTIONS   IN     l"',Ai;    Dl'.l  K  I K  NCI  KS.       'rihllMisI     llcMplent    ill- 

dicatioii  is  the  absorption  of  cartilage  liy  procure,  the  ronit  of  a 
perichondritis  or  a  hematoma,  and  this  afl'oi'ds  the  hesl  results  although 
the  defect  may  he  very  lai',<;'e.  The  paialhn  mass,  howevei-,  will  never 
liold  u|i  the  I'ar  as  caiiilaL;e  diil.  The  preparations  are  the  same  as  in 
lia.sal  injection.-.  Tin'  ii(prKl  Iml  p.-nailin  ,-i\'e.-  lietter  restdls  than  the 
cold,  since  it  s;ives  greater  consisleiicv   to  the  ear. 

Aftei-  the  two  layers  of  the  -kin  of  the  deformed  ear  are  tlior- 
oug-hly  se]iaiated  hy  dis.seelion.  the  parallin  is  filled  into  the  cavity  as 
into  a  hag-  and  allowed  to  solidifx  >niiiew  hat.  Supports  or  splints  made 
by  takin.u'  two  im]nrssions  o;'  the  cither  ear  with  denial  compound 
(front  and  hack)  aii'  employed.  Then  the  ear  is  ronjAlily  sliaped  and 
the  exces.-  <if  parallin  is  allowed   to  escape  throiiuh   the  small   incision 

that  was  made.     Then   apjilv   a    thin    layer  of  cotton,   the   dental   c ■ 

pound  s]iliiit>.  straji  witii  adhe-i\e  pl,-i-ter.  and  haiida;;e  to  the  siile  of 
tlie  head.  Tin.-  i>  left  uiidi.-tiiihe  I  \'ny  one  wcel<  unless  there  -hmild  be 
much  pain  nr  fi'Ver.  Siili.-ei|iieii1 1>  a  cottmi  .-ujiport  and  baiida.u:e  are 
worn  foi-  alinul  three  week-,  iiiitil  (ir,u,aiii/.al  ion  has  taken  ))lace.  In 
the  siili,-e(|neiit  t  re;i  1 1 1  lei  1 1  iif  a  iiewly  made  ear  liv  pla-lic.  an  injection 
of  |iaiafliii  hetweeii  llie  -kill  layer-  mav  iiiidoiiiitedl>  he  lieiielicial  to 
the  coii>i>1eiicy  and  ap|iearaiice  nf  the  I'.-ir. 

Paraffin  Injections  in  Collapsed  Alae. 

.l/r»:c/".s  Mrthofl.— 

1.  Pack  the  nose  (vestilmle)  lirmly  with  cotton. 

2.  Pa.ss  the  needle  under  the  -kill  ovi'rl>  ini;-  the  cartila.ue  at  tin- 
crease  between  the  iio>e  and  cl k.  forward  and  ii|)ward. 

:>.  Distrilmte  the  iiijecteil  mass  (eipiai  parts  of  iJaralliii  and  vas- 
eliii)  over  the  ala  mi  a- to  -I  i  lien  il.  bul  not  lo  any  .ureal  <lejirei',  so  thai 
when  the  cotlnii   i-  iviiioxed   from  the  nose  the  inner  surface  will   iml 


3r)4 


OPKKATIVK    SrUliKKV    OV   THE    XOSK,    'I'llKOAT,    A.XII    EAR. 


approac'li    the    st'ptiiin.      Cottdii    |i;ickiii,u'    is    pcniiithMl    t(i    rcinaiii    for 
twenty-four  hours. 

VIII.     Reduction  Method. 

In  order  to  diminish  as  a  wliole  or  in  inirt  tlie  size  of  a  nose  eidargod 
by  some  pathologic  condition,  traumatism,  or  deformity  of  unknown 
origin,  extranasal,  intranasal  or  combined  methods  may  be  emi)loyed. 
Thus  it  is  that  resection  of  a  portion  of  the  nasal  septum  by  the  in- 


Upper   La+erol 
Ca  f  1 1 1  oj  e 


Lower  Latco.' 
C<^rtil  Aj  c 


Fig.  332.  Fig.  333. 

Joseph's   operation   for   reiUicing   hump,  length,   width   of   nose   and   large   nostrils. 

tranasal  method  Avill  influence  tlio  shai)e  of  the  nose,  but  alone  will 
seldom  straigliten  it.  By  intranasal  metliods,  tliat  is  througli  incision 
within  the  alfp,  redundances  may  be  removed  or  disjjlaced  so  as  to  fill 
out  deficiencies  in  the  nose.  A  very  large  nose,  affected  with  chronic 
rosaceous  hypertrophy,  requires  operation  by  external  methods.  Also 
many  A-ery  large  hump  and  twisted  noses  are  best  attacked  by  external 
methods.    Th(>  minor  deformities,  as  large  alae  or  large  nostrils  or  a  very 


PLASTIC    SnUIKUV    OK    TIIK    XOSK    ANMi    KAH. 


3-)') 


Fig.   334.  Vig.  335. 

KoUc 's  operation   for  luiiiip  nose. 


,<M>M1'/^^ 


Fi;;. 


Beek 's  operation   for  liunip  no 


35()  OPKRATIVE    SflUiEKY    OF    THE    XOSE,    TIIKOAT.    AND    EAR. 

loii^'  li;ni,i;iii,i;  ti))  of  tlic  nose,  are  as  a  I'ulc  licsl  corrci'ti'il  liy  cxlcnial 
iiietliods. 

Joseph's  Operation  for  Reducing  Hump,  Length,  Width  of  Nose  and 
Large  Nostrils. 

1.  An  A-shaped  incision  is  made  over  the  anlerolateial  jjortion 
of  tlie  nose,  jnst  above  the  tij).  A  corresponding  incision  is  iiiaile  aliovo 
tills,  the  distance  depending  on  the  amount  of  tissue  that  is  to  l)e  re- 
moved. The  ends  of  these  incisions  should  reach  to  the  margins  of 
the  alee.     (Fig.  331.) 

2.  A  wedge-shaped  portion  of  the  nose  is  now  tfiken  out,  in- 
cluding the  skin  between  the  two  incisions,  the  underlying  connective 
tissue  and  cartilage.  The  hump  or  crest  of  the  nose,  containing  bones 
and  cartilage,  is  shaved  off  by  means  of  the  cliisel  and  tlie  knife.  (Fig. 
332.) 

3.  The  nose  is  shortened  by  excising  a  wedge-shaped  portion  of 
the  cartilaginous  septum,  with  its  base  at  the  dorsum  of  the  nose  and 
the  apex  running  backAvard  as  far  as  the  bony  portion  of  the  septiam. 
(Fig.  333.) 

4.  Suturing  the  jiarts  togetlier,  one  deep  suture  should  ])ass  be- 
tween the  ui^per  and  lower  margin  of  the  excised  septum  at  the  crest, 
so  as  to  liring  the  point  well  u]i.  The  other  sutures  are  superficial 
ones. 

5.  The  dressing  slioiild  be  sucli  as  to  hold  the  ti])  (if  the  nose  up- 
ward. 

Kolle's  Operation  for  Hump  Nose. 

1.  Make  a  longitudinal  incision  over  the  prominence  of  the  hump 
(Fig.  334)  and  dissect  otf  the  skin  and  periosteum  to  either  side  of  it 
until  it  is  completely  exposed.    (Fig.  335.) 

2.  By  the  aid  of  a  chisel  the  hump  is  taken  off,  cai'e  Ijeing  taken 
not  to  enter  the  interior  of  the  nose  or  to  tear  away  the  mucous  mem- 
))rane.    If  there  is  a  tear  it  should  be  sutured  at  once. 

3.  If  a  broad  bone  defect  is  obtained  liy  the  removal  of  the  hump, 
tlien  by  the  aid  of  a  heavy  forceps  tlie  margin.s  may  be  jiressed  together 
to  obtain  a  sharper  ridge. 

4.  Close  defect  ])y  Halsted  's  subcuticnlar  periosteal  suture. 

Beck's  Operation. 

1.  Instead  of  the  longitudinal  incision,  a  transverse  one  curved 
ujjward,  subsequently  to  be  hidden  by  spectacles,  is  made  across  the 
bridge  of  the  nose.  The  ends  of  this  incision  may  go  to  some  distance 
on  the  side  of  the  nose  and  thus  create  a  flap  which  Avill  easily  expose 
the  hump.     (Fig.  336.) 


n.ASTir  SI -HI ;  Kit  Y  or  tur  nosk  and  kaii. 


Xu 


'2.     By  moans  of  a  cliisi'l  tako  olT  llic  Imiiiii.    ( Fiix.  •">.!7.) 
."..     ("loso  in  tlio  same  inaiuuT  as  in  llic  in-fccijinic  oin'rafioii. 
Ballenger's  Operation  for  Hump  Nose  (Intranasal). 

1.     By  nu'ans  oT  scalpel   tci>l  tin-  lowrr  linrdcr  of  ilic  nasal  hunt's 
and  pass  tlirou.uii  niucous  nii'uiluanr  lidwccn  tlic  skin  anil  nasal  bones. 


Fig.  .■J.3S. 
Ballciiyer's    oiioratioii    for    lu.iiip    nose. 


li,'.  :VM>. 
l!;illciij;rr 's    ojicriitiiui    I'cir    Innj;    iwae. 

2.  Klcvatc  the  skin  from  the  underlying;  anterior  port  ion  of  tin- 
nasal  bones  by  the  ai<i  of  a  Freer  tyj)e  elevator. 

3.  Introduce  the  liallenfjer  reverse  ehisel  and  with  a  downward 
and  forward  imll.  ))aialh'l  to  the  l)rirlir('  of  the  nose,  shave  otT  tlie  hump. 
(Fig.  338. 1 

Ballenger's  Operation  for  Long  Nose. 

1.      Make  two  incisions  thronirh   nni<'ini>  iiicniliraiii'  and  cartilage 

to  the  (i|i|)()sifi'  iimcii|ii'ricliiiniliiniii  :iImi\c   ihr  point   of  the   nose  close 


358  OPERATIVE   SURGEKY   OF  THE   XOSE,   THROAT,   AXD   EAR. 


Fig.  340. 


Fig.  341 


Fig.  343.  Fig.  344. 

Roe's  operation  for  hump,  twist  aud  broad  alsi  or  large  nostrils. 
(Illustrated  by  Beek.) 


Fig.  329. 
Paraffinoma    with    attempted   removal. 


IM.ASTIC    SIUCKIIV    Ol'    Tl  I K     NdSK    ANU    KAIt.  ^'i^ 

to  the  (lorsiiin  and  carry  ilowiiwaid  ami  liack\var<l  to  meet  at  the  llcmr 
of  the  nose.     Disseet  the  iiiiicoiierichoiKlrium  free.     (Kiu'.  -i'llM 

•J.     At  tlio  dorsuiii  of  the  nose  tlie  hase  of  tliis  earlihmc  llap  is  sc\ 
ered  and  the  \vedii;e-8liai)ed  ])ieee  n'nioveil. 

3.  Tlie  nose  is  elevated  tiy  a  mhI  nf  slini,^  liandai^M-  of  adliesive 
])lastei',  an<l  held  thus  fm-  fiMui  I'nnr  In  i-i^-ht  da\s. 

Roe's  Operation  for  Hump,  Twist  and  Broad  Ala  or  Large  Nostrils. 

1.  Make  an  ineisiun  at  the  jinietion  nf  the  iiinei-  ahir  >kin  snrface 
with  tlie  na.^al  nuiei.us  nienihrane,  and  pa-s  hehiw  the  .•<kin  i>\ci-  the 
eartilaije  and  na.-^al  hone.s.     (Fii;.  iUO. ) 

2.  Elevate  the  skin  and  suhcntaneous  edinieetive  tis.-iie  liy  means 
of  elevators  (the  author  ]»refers  Mayo  scissors,  as  liy  npenini;-  the 
blades  the  tissues  are  sei)arated  witii  the  least  traumatism)  until  tlie 
entire  hump  is  exposed.     (Fijj:.  .S41.) 

3.  By  means  of  a  small  saw  the  liuni]i  made  np  nl'  cartilage  and 
bone  is  sawed  olT  (  Fiii'.  .'14'_')  and  reniuved.  If.  a>  i>  freipientlx  the 
case,  the  humji  nose  is  at  the  same  time  twisteil  ami  (lepres>ed,  the 
hump  is  sawed  ulT  paitially.  Imt  is  left  attached  aliove  to  the  liliri)us 
tissue  as  a  sort  of  a  pedicle  and  slid  nvei-  into  the  (K-jiression.  lli-re  it 
is  subsequently  retained,  i  l'"ms.  .14;!  and  :144.)  This  fibrous  pedicle 
is  not  ab.solutely  necessary,  as  the  bone  and  cartila.ne  chip  will  live  any 
way.  If  the  depression  be  ,a;reater  than  the  l)one  cartila,a;e  chip  can 
fill  out,  small  subcutaneous  tissue  llajjs  are  turned  back  into  the  de- 
pression. These  are  as  a  rule  taken  fi-om  the  tip  of  lateral  imrtions  of 
the  ahv,  which  also  are  lai^e  in  inaiix  cases. 

4.  Either  a  soft  nielal  o|-  adhesive  retention  diessini;'  is  applied 
over  the  nose  and  the  inei>ioii  within  tiie  ala  is  sutured. 

Roe's  Operation  for  Broad  Alae  and  Large  Nostrils,     i  I";--.  .'!4.').) 

1.  An  incision  is  nnuk'  within  the  nostrils  cIumt  to  lln'  exteiior 
than  in  the  preceding  o])eration. 

2.  The  cartilage  is  liberated  and  part  of  it  is  excised  to^^^ether 
with  some  of  the  subcutaneous  lissin-.     (  I-'ig.  ■'A(\.) 

'■■>.  Suture  and  insert  two  small  rnlii)er  tulns.  Fig.  .■J47  shows 
final  results. 

Beck's  Operation  for  Hump  Nose. 

1.  Lift  np  tip  of  the  no~e  and  make  with  a  knife  a  small  semi- 
circular incision  in  the  anterolateral  poitioii  of  the  vestilnde  at  the 
n^l(•lM•^taneon^  jnnctinn  of  the  cartilaire  and  hone. 


360 


OPKl'vATlVK    STRCEltV    OF   THE    XOSE,   THROAT,    AND   EAR. 


Fig.  345.  Fig.  346.  Fig.  cil,. 

Roc's   oiseiation   for   brnail    al:i'   or    lar^o    nostrils.      (Illustrated   by   Beck.) 

2.  Dissect  over  the  liuiiip  with  Mayo's  scissors  as  in  Fig.  348. 
With  the  same  scissors  engage  and  sever  the  hump  which  is  nsually 
made  np  of  cartilage. 


-c^X 


^^^^^^^^ 


0{!W^  1 1/1 .-, 


Fig.  34S. 
Beck's  operation  for  hump  nose. 

3.  Displace  this  fragment  by  external  manipulation  and  by  the 
aid  of  fine  forceps  or  the  scissors  in  the  eventually  existing  depression 
(if  none  exist  remove  the  piece). 


iM.ASTic  sri;r,Ki;v  (ie     riiK   Nosr.  anh  i.\it. 


:{(i 


4.  If  tho  base  from  wliidi  llic  liiiiii|i  is  rciiKtvcd.  is  vi'iy  liidiid  ami 
sliarp,  the  ediri's  may  In-  HIcil  niT  witii  a  straiirlif  rasp  or  sliavcd  otT  witli 
a  chisel. 

5.  Till'   liinml   i'\|)l('.->ril    I'nuil    till'   caxitv    is    lini|i|iril   ;i\\;iy   ail>l   ail 


CL 


Fig.    .349. 


Fig.    350. 


Fig.  351. 
Kiilli^'s   ii|iorution    for   long    lip   iiodc. 

adliosive  jilastcr  is  ilrawii  tiiiflitly  over  the  luiiliir  i^'i  \\\v  imsc  wilii  im 
dressing  between  it  and  tlir  skin. 

6.     One  silk  stitch  is  ii>cd  in  chisc  the  wcnind. 

Kolle's  Operation  for  Long:  Tip  Nose. 

1.  .\!;iki'  Jill  incision  on  cither  side  thro\i«:ii  the  entire  lliickness  of 
the  nose,  indudiiii;  the  septum,  as  shown  in  Fiir.  •!41».  lii^innina:  at  c, 
downward. 


302  (Vl'KltATIVK   srUCERY   OF   THE   XOSE,   THROAT,   AND   EAR. 

l'.  From  !■  to  //.  in  a  natural  curx'c  linr,  all  the  tissues  of  the  alu' 
arc  scN'crod. 

.").  A  short  u])\var(l  cut  is  made  tlircuiiii  tiic  entire  tiiickncss  (if 
the  columella  at  r.  fi'om  which  point  the  scjitum  is  cut  as  shown  in  the 
(lotted  line  d.  towards  e. 

4.  The  tip  h  of  the  part  (/  is  now  cnt  ofl',  leavini;-  the  nose  as  in 
Fig.  350. 

5.  The  front  part  a  is  now  sutured  to  the  remaining  portions  of 
the  columella  at  h,  and  the  cartilages  of  the  alfp  where  they  are  pro- 
truding are  excised  to  such  an  extent  as  to  permit  union  of  the  skin 
over  them,  as  .shown  in  Fig.  .351. 

IX.    Prothetic  or  Artificial  Noses. 

There  are  frecjuently  anatomic,  jiathologic  and  social  conditions 
that  require  the  correction  of  the  nasal  deformity  to  l)e  made  by  the 
aid  of  artificial  devices.  It  can  be  said  without  (juestion  that  so  far  as 
the  appearance  is  concerned,  at  least  if  not  too  closely  scrutinized,  an 
artificial  nose  that  is  correctly  made  looks  much  better  than  one  that 
results  from  the  most  of  the  best  surgical  procedures.     (Figs.  352-355.) 

For  instance,  in  cases  of  carcinoma  which  have  been  operated  upon 
to  the  extent  of  removing  the  greater  part  of  the  nose,  there  will 
naturally  l)e  some  hesitation  about  performing  a  plastic  operation.  In 
cases  where  the  face  is  all  scarred  up  it  is  much  better  to  employ  an 
artificial  nose.  There  ai'e  some  people  who  have  not  the  necessary 
time  to  have  plastic  woi'k  done  on  their  noses  by  reason  of  the  necessity 
of  making  a  living  and  i)roviding  for  their  families. 

These  artificial  noses  may  be  made  to  fit  any  kind  of  defect  and 
are  usually  held  in  place  by  spectacles  and  adhesive  (actors')  paste. 
The  making  of  these  noses  is  left  to  a  specialist  in  this  line,  but  only 
under  the  direction  of  a  physician,  since  the  condition  of  the  nose  nnist 
be  thoroughly  examined  before  fitting  an  artificial  nose. 

Artificial  Supports. — In  noses  in  which  the  bony  framework-  is 
destroyed  or  absent  one  may  introduce  -vvdre  or  lubbei-  supports  made 
especially  for  each  individual  case.  In  cases  of  lues,  in  which  there 
exists  a  perforation  in  the  hard  palate,  a  sort  of  a  horn  may  be  vul- 
canized i;pon  a  dental  plate  that  will  ])ush  the  collapsed  nose  forward 
and  thus  sujipoit  it. 

X.     Orthopedic  Method. 

By  wearing  certain  forms  of  apparatus  which  usually  must  be 
specially  made  in  each  individual  case,  a  deformity  may  be  changed, 
especially  in  early  life  oi-  when  it  follows  a  traumatism.    It  is  also  pos- 


ri.\>rir   >^i;l,l.i;^    m     rm:    mi>i-.   ami   i;.\i;. 


:5(i:5 


FIc.   355. 


364 


Ol'KKAriVE    SnuiERY    OK   THE    NOSE,    THROAT,    AM)    EAR. 


siblo  to  correct  collapsed  or  saddle-liack  nose  bv  s])ecia!  iiietliods.     (Fi^'. 
324.) 

XI. — Operations  for  Closing-  Perforating  Septum. 

Goldstein's  Operation. 

1.  Freshen  iij)  the  edges  of  the  perforation  and  elevate  the  mneo- 
lierichondrium  from  the  cartilage  for  al)out  one-half  inch. 

2.  Kemove  a  small  rim  of  the  cartilage  all  along  the  perforation 
by  means  of  Ballenger's  single-tined  swivel  knife.     (Fig.  356.) 

3.  Outline  a  nmcoix'i-icliondi'ial  flajt  on  the  most  convenient  por- 


Fig.  356. 


P"ig.  357 


Fig.  308. 
Goldstein 's   operation   for   perforation   of    septum. 

tion  of  the  septum,  with  the  hinge  pedicle  at  the  margin  of  the  per- 
foration. The  author  would  suggest  the  use  of  the  cautery  in  order  to 
destroy  the  epithelium  so  that  tlie  flap  may  heal  more  easily.  (Fig.  357.) 

4.  Dissect  this  flap  and  bring  it  between  the  two  layers  of  the 
mucoperichondrium  about  the  perforation. 

5.  Suture  through  and  through  by  a  quilted  suture  with  the  aid 
of  Yankauer  needle.     (Fig.  358.) 


I'l.ASTIC    Sl'Kl'.KItY    OK    Till'.    NOSK    AND    KAIi. 


365 


Hazeltine's  Operation  for  Perforation  of  Septum. 

1.  l''rc>ll('ll    ll|>    llir   Ili.llLlills   <■  I     (  l-'ii;-.   '.','>'.>)    ;iMil    i'l<'\;iti'    tile   Illin'ii- 

l)eriohonili"iiiiii  (ii>  in  tlit-  siil)imicmis  n-scfliim )  wIutc  the  ;inti'ii()r  tliip 
lii'.^;. 

2.  All    iiicisiuii    lhii)Ui;li    llu'    iiiiic(>|icrii-li(iniliiuni    ■•iliout    oiii-  hall" 


Fiir.    .35!l. 


Fig.    ."CO. 


Fig.  361. 
niizollino'.s  o|ii>riilion  for  p'-iforHtiiiii  of  scptniii. 


to  Olio  inch  anteriorly  to  iicrforation  (/;-/*,  Kiii;.  i!.")!!)  is  iiiaih',  mikI  flu' 
flaj),  witli  pcdich'  altovc  an<l  lii'h)\v.  is  dissi'dcd  as  far  as  tlic  iiciToralinn. 
■"5.  If  thf  aiitrrior  flap  was  iiiaih'  on  the  rinht  side,  then  make  tlio 
posterior  Hap  ('■-»■,  l-'iy.  .'!.')!))  on  tlie  h-ft  siilc.  liy  a  siiiiihir  incision 
tlirou<jh  the  nnicopcriclion<lriiiiii  almnl  oiu'  halt  to  mii-  inch  lia<'l<  of 
perforation. 


366  ni'KKATlVK    sri'.CKIIV    OF    TIIK    XOSK,    TIinOAT.    AND    KAII. 

4.  Aiiproxiinntc  .-iikI  suture  jintcrioi-  fla])  to  posterior  inarain  of 
IH'vfoiatidU  (/-/.  l'"ii:'.  •■!•)!')  and  slide  the  posterior  fla])  of  the  opposite 
side  forward  and  suture  to  the  anterior  margins  of  ]ierfor.ntion  (d-'l. 
Fi,-.  -Kil).     Denuded  aivas  (d-a)   from  llie' flap  Ileal  l>y  ,i;ranulati(ni. 

Goldsmith's  Operation  for  Closure  of  Septal  Perforations. 

1.  Kxeise  margin  of  perforation  li\'  the  Italleu^er's  siii,iide-tiiie 
swivel   knife. 

2.  Separate  the  mueopei'icliondrial  Hap  on  either  si(h'  all  around 
the  ]ierforation. 

."!.  Take  a  piece  of  cartilage  eitiier  from  anotiier  case  just  ojier- 
ated  n])on  for  deviation  hy  the  submucous  method,  or  a  jiioce  of  sheep's 
septal  cartilage,  wJiich  must  be  larger  than  the  perforation. 

4.  Slip  this  cartilage  plate  into  the  dissected  fla]is  and  replaee 
earefuliy  all  around  the  ])ei'foration. 

.").  I'ut  in  anteriiu'  nas^d  splints  to  I'etain  the  cartilage  and  nuico- 
perichondrium  in  ])lace  for  forty-eight  hours. 

'i.  Subsequent  cauterization  to  assist  in  epithelialization  ami  a()- 
plieation  of  scarlet  red  ointment  constitute  the  after-treatment. 

OTOPLASTY. 

()to])lasty  is  a  subject  that  hiis  i-eeeived  \ery  little  attention  as 
(■omi)ared  with  rhinoijlasty,  and  most  text  books  contain  very  meager 
information  on  the  subject.  However,  nuich  better  cosmetic  results 
are  obtained  than  in  nasal  plastics,  es]iecially  in  deformities  or  mal- 
])ositions.  in  the  absence  of  the  eiitirt'  or  a  greater  portion  of  the 
ani'icle,  the  results  exce]it  witli  ]irothesis  are  very  unsatisfactory.  There 
is  one  comfortim^'  fact  that  in  women  deformities  of  the  ear  may  be 
hidden  by  long  bail'.  Kai'  plastics  are  performecl  jiriuci^ially  for  cos- 
metic reasons,  since  the  ]iliysiologic  i'uuclion  is  but  slightly  influenced 
unless  it  be  in  cases  of  congenital  atresia,  with  ))resence  of  a  good 
middle  ear  and  auditory  nerve  apparatus. 

Classifications  According'  to  Kolle. 

T      Tj  •     I        1  «  •  I  l-'iiilateral. 

I.     Freaurnnilar  dehciency       p-i.  f  . ..  i 

I  Tnilateral. 
II.     Postaurieular  deficiencv.     ,,•,    ,     „-i 

1)1  lateral. 


iM.Asiic  sii:(ii:i!\    (11     iiii-:   nosi'.  anh   icau. 


3G? 


General  Classification. 

1.       Ma.lntiji    (liiriiV  ,.;ii-). 

II.  As_\  iiiiiiclry  ol'  the  two  oirs. 

111.  I  K't('niti)|i\    (f.-iLxc  id.sitioM  nf  tlic  .•uii-i<-|c). 

I\  .  SyiR'chi.-i  (if  the  ixislcrior  siiit'iicc  df  tlic  niiriclc. 

\  .  Pru.ji'ctiiii:'.  idll  or  doii'  i-iiis. 

\  I.  I'uinlcd  car  (  I 'arwiiiiaii  tnlicrck"). 

\ll.  Maca.-us  car. 

\'lll.  Wildcnmitli's  car. 

1  .\.  .\l),<ciicc  (if  helix. 

.\.  Ldhiilc  <lcf(iniiitics  aiiij  aliiKiniialilics. 

.\l.  Syiiccliia   (if  Idliulc. 

.\ll.     Sliii\clc(l   car   fdlldwiiiL;'   |icric-lidii(liitis   (ir   iiifcctcij    licmafdiiia 
(ir  alisccss. 

.\lil.     'riaiiniatic  (K'slnictidii,  cdiniilclc  (ir  |iartia!. 

.\l\.      I'dlidtia. 

XW     Microtia. 

Usual  Operation  for  Macrotia. 

1.      H.xcisc  a    \'--lia|i((l    sc:;iiiciil    of   flic  auricle,   incliuliiii^   all   the 
structures  at  tlic  upiici'  au>l  laruci-  jiart.     'I'lie  l»ase  of  tlu-  \'  is  at  tin- 


Fig.  362 


Fig.  3(5.;. 
UmuuI  oiHSrntion    for   inncrutiii. 


368 


OPEUATIVE   SUlHiKItV   OF   THE   NOSE,   THROAT,   AND   EAR. 


external  border  of  the  ear.  (Figs.  .')til2  and  060.)  The  size  of  tlie  wedge- 
shaped  piece  to  be  removed  will  depend  on  the  size  of  the  deformity 
to  be  corrected. 

'2.  ?iXcise  a  narrow  wedgc-sliapcd  st'uniciit  fi'om  tlic  Iowit  lialf 
of  the  auricde,  the  base  of  this  wedge  being  at  the  incision,  the  apex 
dii'ected  towards  the  l()l)ule.  (Fig.  'MU.)  This  is  necessary  to  mak'c 
the  upper  and  lower  portions  of  the  auricle  lit  for  exact  a])pr()ximatioa 
of  the  helix. 

3.  Sntnre  the  lower  Avedge  first  and  then  the  large  transverse 
defect  after  exact  ajiproximation. 


Fig.   365.  Fig.    36G. 

Pnrkhill's  npcratioii   for  maorotia. 


Parkhill's  Operation  for  Macrotia. 

1.  Make  an  incision  tiirough  all  the  structures  in  line  with  the 
curve  of  the  antilielix. 

2.  From  each  exti-emity  of  this  incision  make  a  curvilinear  in- 
cision towards  the  enter  margins. 

3.  A  small  tongue-shaped  fla]i  is  further  excised  from  this  last 
ipcision  towards  the  external  border,  in  order  to  shorten  the  long- 
diameter  of  the  ear,  and  the  crescentic  excision  will  make  the  width 
of  the  ear  smaller.  This  will  make  a  crescent-shaped  defect  with  a 
little  tongue.     (Fig.  365.)     Suture  defect.     (Fig.  3G6.) 

Cheyne  and  Burghard's  Operation  for  Macrotia. 

1.  Excise  a  V-shaped  piece  of  the  auricle  from  the  upper  and 
outer  part,  the  acute  angle  of  the  V  being  carried  almost  into  the 
conclia.     (Fig.  3fi7.) 


PI.AMK      >l    i;c;l".KV    Ol"    TIIK    NOSK    AXII    KAIt. 


36!> 


-.     «  oni'siuiiidiiii;'  lo  the  upiiri-  lnir.li'f  nl'  lli niclui  .-i  -cinliiiiiiir 

incision  is  niixlc  tiironyli  ;iil  tlic  -1 1  ik-i  iiifs. 

">.  I'liuM  liic  latti'r's  I'xtri'ini'  I'uils  two  sliorl  nirvctl  incisions  are 
niinlc  III  uu'ct  the  \'-sliai)i'(I  incision,  rcnioviny-  llic  two  jiicccs  tims 
formed.     (Fiy.  ;>(i7.) 

4.  Tile  parts  are  lirouiiiil  tunetlicr  mnl  ^ntnred  on  liotli  <idi~  >i\' 
the  anrielo.     (Fig.  368.) 

Goldstein's  Operation  for  Macrotia. 

1.  Make  a  curvilinear  nicisitm  down  to  tin'  cartilage,  witli  its 
convoxity  directed  to  tlie  ontcr  jnarnin  of  tiic  car.  on  the  jiosterior 
surface  of  tiie  auricle.     (  l''i.ii-.  ."!()!>.) 


Fig.    367.  Fig.    368. 

ClieyiU'  mill   Hiir^'liiiurs  oprnitidii    fur   iiiiu-ri)ti;i. 

2.  Dissect  off  tliis  llaji  and  lay  o\  cr  tiic  mastoid  ri'iiioii.  (  Kiii'. 
370.) 

3.  Cut  througii  tile  cartiiai;e  in  the  iierpeiidiciilar  direction  of 
tlie  ear  and  curve  the  incision  at  each  extremity  for  a  short  di.stance 
in  order  to  make  a  sort  of  a  cartilam'  flap,  (ircat  care  must  be  exer- 
cised not  to  cut  tlironjiii  the  skin  on  tlic  aiili  lior  surface  of  auricle,  in 
other  words,  not  to  hnttonhole  it.     ( I'iii'.  37<l.) 

4  With  a  dissector,  as  employi'il  in  a  sulimucons  i-csection  of  tiio 
septum,  the  dermopeiichondrimn  is  dis.sected  olT  from  the  cartilage, 
thus  making  the  cartilage  flap,  and  tiie  tlissecfion  is  continued  a  little 
beyond  the  necessary  limits  so  as^  to  eiuible  one  to  >lide  the  llaji  over 
with  greater  ease. 


370  OI'KItATIVK   sriHiEUY   OF  THE   NOSE,   THHOAT,   AXD   EAR. 


Fis.  ?.m. 


6- 


Fig.  371.  Fig.  372. 

Goldstein's  operation  for  macrotia. 


rr.ASTic  smcKKV  oi'  tiik  xosk  axd  kaii.  .h  I 

.").  Disscet  also  tlu'  tli'i-iii(i|icri<-li(iiiilii\iiii  .•inlcriurly  rrmn  tlic  i-x- 
tonial  iiDVtioii  ol'llic  i'XiuisimI  fiii'tilaiic  liccaiisc  tlic  miIis(m|iiciiI  sutiuiii-i' 
will  liavi'  to  lie  doiic  at  that  point. 

(i.  Pass  a  siiiall  siiar|i  (Mirvcd  needle  anaed  with  line  clironiieized 
catsut  tlironu'li  the  nitper  part  ol"  thi'  internal  eaitilaL:c  Map  (which  will 
boconie  the  ovoiridinin"  one).  Then  at  the  same  place  pass  the  needle 
tlironiih  the  external  eartilaiife  flap,  which  will  liecmne  the  overridden 
one,  and  talsiny'  in  a  small  hit  of  cartilage  ennie  ont  Ihi'on.uh  lioth  flajts, 
coniiiletiny  oiu'  mattress  snlnre.  Another  snlnre  of  the  same  type  is 
made  in  the  lower  portion  of  the  im'ision.  and  tiie  )>arts  are  re;id\  for 
sntnre.     (  V'mx.  •!71  .) 

7.  While  the  assistant  hohls  the  parts  touetliei-  so  as  to  iict  an 
overridinit'  ol'  the  internal  flap,  the  sntni'es  are  tieil. 

S.  The  jiostorior  dennoiierichondrimn  tlap  is  In-oniilit  liacl<  a^ain 
ami  sntnreil.     (Viix.  '.u'2.) 

Goldstein's  Operation  for  Projecting  Ear. 

1.  ^lake  two  cnrNilini'ar  incisions  iiaci<  ol'  tln'  ;iuiicle,  one  n.-nmi: 
its  convex  border  towards  the  onter  border  of  the  ear,  the  other  towar<ls 
the  oociimt,  thns  cveatin.u-  an  elliptical  Hap  of  skin.     (Fiu;.  -'w.'!.) 

2.  Dissect  off  this  skin  Haji,  exposini;-  the  iieriohondrinm  of  the 
auricle  and  the  i)eriosteniii  of  the  m.istoid.     (Fii;-.  'M'->.) 

0.  Excise  an  eUipti<'al  jioition  of  the  cartilaii'e  of  ;i  -^i/c  dependinL: 
upon  the  amonnt  of  projection  pre>eiit.     (  l*'iu.  •"■74.) 

4.  Draw  tlie  cartila.u'e  towai-ils  the  mastoid  rcLiion  ,inu  snlnre  to 
the  ]ieriostenin  at  this  point.     (  Fi.u'.  'u'>.) 

.'}.     Close  the  skin  defect  by  a  few  interrupted  sninres.     (  Ki.u'.  •'~i<.) 

Beck's  Operation  for  Roll  Ear  or  So-called  Dog-ear.     i  Fii;.  .177.) 

1.  -Make  an  incision  tliron,::!'  the  skin  on  the  jioslerior  part  of 
the  auricle  in  line  with  the  nsnal  site  of  the  antihelix. 

2.  Dis.sect  the  skin  freely  on  either  side  of  the  incision,  bnt  not 
the  ]ieiichondrium. 

.'!.  Kxcise  a  very  thin  >liver  of  cartila:;c  the  whole  length  of  the 
skin  incision  in  a  curvilinear  slnipe.      {V\ii.  -'mS. ) 

4.  Demi  back  the  helix  and  form  an  antihelix  by  donblini'-  the 
eartilajfe  upon  itself.  Hold  the  parts  lou'ether  on  the  anterior  surface 
of  the  ear. 

5.  Pass  two  mattr<'ss  sntur<'s  of  silkwoi-m  unt  tlnon.^h  the  skin, 
perichoudiinm,  cartilaire.  two  layers  of  perichomirinm,  cirtilaire,  peri- 
chondrium and  skin.  These  are  tied  over  jiieces  of  rubb.T  <i--n.'  in 
order  ni>t  to  cut  into  the  >kin.     (  f'ii;.  'M'.K) 


372  OPERATIVE   SURGERY   OF  THE   NOSE,   THROAT,   A::^D   EAR. 


Fig.  375.  Fig.   37(1. 

Goldstein's   operation    for   projecting   ear. 


Fig.  378. 


Fig.  379. 


Beck's  oiieratiou  for  roll  ear  or  so-called  dog-ear. 


IM.ASTIC    sriiCKItV    (»K    Tl  I K.    NOSK    ANH    K.AK.  .)(.) 

(■>.  l-'Acisc  >m:ill  imitiniis  dI'  cxcoss  skin  mi  \\\v  |iu>!ciin|-  siii-r;ii'(< 
i\\u\  iiiJiUc  ;i  sulpi'uti«'ul;ii-  sutmc. 

This  siiiiic  oinTiitioii  cjiii  Kc  ;i(liipt«'<i  I'lH-  the  ruriiiatioii  n\'  an  niiti- 
liclix  in  an  cai-  that  is  nut  inlircl. 

Szymanowski's  Operation  for  Reconstructing  an  Auricle. 

1.  Makf  an  inci.-ion  as  outlined  in  l''i,i;'.  '^S^).  Imck  o\'  tlic  iiidi- 
incntai>  car  ur  external  auditory  iMeatn>.  ahont  the  -ize  of  tlie  pinna 
on  tile  u]»i)i)site  si(h'.  taUiuii'  in  tlie  sUin  and  all  sui)eutaneous  tissue 
]iossible. 

•_\  Disseet  tlie  ahove  oiitliiie.l  (la|.  and  fold  a1  the  eouslridi'd 
iiiiddh'  part  so  as  to  hriu.ir  tlie  raw  surfaces  in  appositimi. 

.■).     Suture  alouii:  the  uiar.yins  aliove  and  below. 

4.  Cover  the  denuded  ari'a  of  defect  by  skin  urafts  or  slide  a  liap 
from  the  occipital  reniou  and  snjiport   posteriorly  by  liau/.e  pads. 

Siihsequeuf  Correction. 

5.  Incise  al)nve  and  below  as  sliow  n  in  |-"i,i;.  ilSj.  |)iaciiif;'  small 
trianijular  llajis,  back  of  the  nniicle  ami  liiiiminu  the  latter  forward 
into  u  more  i)rojpctiii<;-  shajie.  .\l.-o  excise  a  small  portion  of  the 
newly-fonned  auricle  from  the  lower  inari:in.  to  shape  a  lobnle. 

Beck's  Operation  for  Synechia  of  Auricle  to  the  Mastoid  Squama. 

1.  Sever  the  adherent  ear  from  the  ma.stoid  surface  and  ])lace 
between  the  surfaces  irauze  or  rulilier  tissue  to  prevent  reunion  ami 
wait  for  iiranulation  fonnation. 

'2.     Make  a  correctly  outlined  tlap  to  cover  the  mastoid  region  as 
well  as  posterior  surface  of  auricle,  on  the  forearm,  on  the  side  opjio- 
site  to  the  synechia,  since  the  subseipu^it  immobilization  is  more  com 
fortable  in  that  way.     Place  rubber  tissue  1m  low  this  f^ap  to  ju'event 
its  reunitini"-  ami  allow  it  to  lu-come  thicker. 

0)if  WeeJc  Latrr. 

'.').  Fresiien  up  the  surfaces  on  the  nia>toi(l  ri'uion,  tnrii  the  anncle 
forward  and  suture  into  the  forearm  llap  on  the  greater  portion  of 
the  defect.     (Fi.ir.  '^X-2.) 

4.  Ajuily  re.irular  iilasti'r  retention  ca^i  a^  in  tli-  Italian  jilastic 
operation  for  th»»  nose. 

Teu  Dni/s  Latrr. 

5.  Sever  ]iedicle  from  forearm  and  snture  on  all  sides,  special 
care  beinj;  taken  to  make  a  natm-al  lold  at  the  insertion  of  the  auricle. 
This  is  best  aecomiilislied  by  a  sjirinu  wire  like  a  spectacle  frame  over 


374  OPERATIVE    srHCEKY    01'   THE    XOSE,    THROAT,    AXI)    EAI! 


Fig.  381. 
Szymauowski's  operation  for  recoiistruetiu!;  an  auricle. 


ri.ASTU'    SfKliKKV    HT    TIIK    NOSK    AM'    KAK.  ■>!  ■! 

soiiit'  liulil  >lir>siiii;.  to  l»f  lit'ld  l>\  the  wc.-iriim  nl'  s|)cct;i<-li's  fcir  the 
tiiiif  lifiim. 

ti.     S\itiirf  ilrl'cct   ill   forciinii. 

liisti-iid  III'  usiiin-  tlif  tliij)  troiii  llic  fon'Mriii  one  or  two  Wull'c  iir;ifts. 
or  Tliiorscli  ur.-it'tiiii;-.  iii;iy  lie  ciiiiiloycd  In  cover  llif  ildicl.  AiiJiiii, 
the  sli.liii:;-  ov.t  of  ;i  tlap  iVoiii  the  l;itfi;il   |iortioii  ol'  \\\<-  occi|ml.  cvcii 


Kig.  382. 
lifck's  iipiMHtiiiii  for  sjTiechia  of  miriclo  to  nin.stoiil. 


llioiiiili  it  coiitiiiii  liiiir,  to  cover  the  iii;i>toi«l  I'ciiioii.  will  iiid  n  i^rejit  dcnl 
and  prevent  the  further  i'oniiiilioii  of  a  .synechia  on  tlie  )iosteri"'r  -m- 
face  of  the  aurieh'.     Tlie  latter  may  he  envorcd  liy  -kin  L!raft>. 

Roberts'  Operation  for  Absence  of  Ear. 

Thi.s  anlhor'.s  |iidceihire  i>  \eiy  iniieh  lii<e  tile  operation  iihistrated 
in  Vlixa.  .JS.'i-.'JSi;,  except  that  he  employs  only  skin  and  snlieutaneous 
ti.s.sue. 


:i7(i 


Ol'KKATIVK    SriUiKi;V    (IK    TIIK    NOSK,    THKOAT,    AND   EAR. 


Simple  Operation  for  Colobomata. 

I*]\cisc  the  scar  mari;iiis  so  as  to  ohtaiii  fresh  deriiial  layers  and 
suture  auteriorl\-  as  well  as  iiosterioiiy  with  special  care  at  the  tip 
of  the  lobule,  since  keloid  is  lialile  to  form.     (Fi.y's.  387  and  388.) 

Green's  Operation  for  Colobomata. 

1.  Remove  the  cicatrized  skin  from  the  notcii  without  cutting  it 
away  at  the  ti])  limits,  Imt  judl  it  down.     (Fi^-.  38i).) 


Robert's    operation    for    absence    of   car. 


2.  Brini;-  the  (k'uuded  surfaces  to.i-'ether  ;nid  eiiiploy  the  little 
rihl)on  of  skin  to  make  a  rounded  mars'in  of  the  tip.     (Fig.  3L)U.) 

Monk's  Operation  for  Prominent  Ear. 

1.  Excise  a  strip  of  skin  and  subcutaneous  tissne  in  the  form 
illustrated  in  Fig.  391,  making  the  one  incision  all  along  the  attachment 
of  the  auricle  and  the  other  corresponding  to  the  degree  of  projection. 


iM.ASTic  SI  i;i;i;i!V  of  tiik  xosk  anh  kak. 


Tlic  llap  is  iikkIc  I'itlirr  IhiukI  mi  tlic  tnp.  iiii<liili-  or  Im.i1(iiii,  iI 
oil  tlic  lociitioii  ol'  till-  in-oiiiiiK'iici-. 

-.     JStitc'hos  aro  cjiiTriilly  iii>plif(l  so  as  to  piicUcr  llic  tlfl 
ouulily,  and  pcrrcct  a|iproxiiiiatioii  i>  iiiipfialiv f. 


•|M'ii(liii:j 
r.-t   llior 


Via.  :!87.  Fig.  ass. 

Simple  operation    for  eololioniata. 


ViK.  300. 
Onoii's  operation    f.ir  eololiomnfa. 

Kolle's  Operation  for  Projecting  Ear. 

1.  Maki'  an  incision  on  tlic  liack  of  the  aurii-ic  tlncc-(|iiartcis  of 
an  imh  fnini  it>  mitci-  niaririii.  lic.iiiiinirin-  aliovc  at  tin-  sulcus  and 
cnrvinL;  n|i\vaid  and  outward  ami  tMcii  gradually  downward  nntil  the 
lowiT  iiait   (if  llic  sulcus  is  reached.     The  >l<iii  oiilv  is  incised. 


378 


OPEKATIVE    srn(;Kl!V    OF   THE    NOSE,    TIIKOAT,    AND   EAK. 


'2.  ISIccdiiii;  ;it  (iiicc  takes  |ilaci'  and  liy  turning  the  auride  over 
the  iiiasloid  and  side  nf  hi'ad,  an  dutlinc  in  lilood  is  made  wliich  cor- 
ros]ionds  to  the  ineision  to  be  made. 

.■].  Tliis  second  incision  Avlien  comideted  "will  outline  a  heart- 
slia]ted  tla]i,  which  is  removed.     (Fi.ii'.  ."Il'l!.) 

4.  An  elliiitical  piece  of  cartilage  is  removed  in  extremely  pro- 
jecting ears  without  going  through  the  anterior  skin.     (Fig.  393.) 

5.  Suture  the  cartilage  with  catgut  separately  and  then  apply 
continuous  sutures  from  above  downward  to  the  skin  margins  to  close 
the  defect  and  to  firing  the  ear  close  to  the  side  of  the  head. 


Fig.  .391. 
Monk's  oiievatiou  I'or  prominent  ear. 


Fig.   .■'.!)1\  Fig-.   393. 

Kolle's  oi^cration  for  projecting  ear. 


fi.     Place  a  pad  over  ear  and  use  a  bandage  that  is  not  too  firm. 
7.     Allow  stitches  to  remain  for  nine  days  and  do  not  disturb  the 
wound. 


Postauricvilar  Deficiencies  or  Retroauricular  Fistulse. 

These  are  as  a  rule  the  result  of  mastoid  operations  (radic;al) 
which  formerly  were  performed  by  leaving  a  large  retroauricular 
drainage  for  a  long  time;  when  healing  took  place,  the  cavity  was 
lined  by  epithelium  continuous  Avith  the  outside  skin.  Some  of  the 
cases,  even  when  the  posterior  bony  canal  was  taken  away  and  the 
membranous  canal  was  split  in  the  usual  iilastic  manner,  remained 
open  in  the  liack  of  the  ear  and  then  there  was  a  cavity  which  was 


IM.ASTIC    SII!(;I:KV    DK    Till'.    NOSK    AMI    I'.AK.  379 

liii.'.l  li\    i'|iicli'iiiiis  (•(.iitiimuiis  willi  tlir  skin  of  lli.-  .•xlcniiil  .■iiiditnry 
(•anal  and  tlir  skin  on  tlic  iiustcrini-  vm  f,,, f  tli,.  aiiriilr. 

Trautmann's  Operation  for  Closure  of  the  Posterior  Deficiencies. 

1.  ln<-isc  tile  listnla,  makini--  two  cn-srcntir  ll.ips  wilii   tlnir  ci.i 
(Ifinial  layiT  lookinn'  towards  tlic  anditory  canal.     (I'"ii;'.  .1114. 1      (This 
is   done   only    in    tlmsc   t-ascs   in    wliirli    the   nsnal    plaslic    of   cxlnnal 
anditory  nu'atns  in  c  <iniircti«in  wilii  the  radical  inastnid  n|ii'iation  has 
Ix'cn  jii'rforuuMl.) 

2.  Stitch  these  two  tlai>s  with  latiiut.     (Ki-    :!:»•').) 

.■>.  nissect  freely  the  skin  and  iieiiciiondrinni  over  the  ]iinna  and 
also  the  skin  and  periosteuin  over  mastoid  i-eiiion.     (  Ki";.  89t5.) 

4.     I'nite  the>e  hy   inten-npti'd  >utnres  oV(  i-  the  two  lower  flaps. 
(Fisr.  :W7.) 
Von  Mosetig-Moorhoff  Operation. 

1.  .Make  a  tonune-shaped  tlap  lielow  tlu'  li.-tiiioiis  opening,  leaving 
tlie  hiuiiod  ])ediflo  at  the  lower  niar.iiin.     (Fig.  398.) 

12.  Dissect  loose,  Init  not  too  dose  to  the  niai'.siin  of  tho  ojieninij; 
or  else  too  little  hlood  supply  will  remain  to  nourish  the  Hap.     (Fig. 

0.  I'^reshen  up  tiie  margin  of  the  listnla  and  loosen  the  margin 
thoroughly  for  suture. 

4.  Turn  the  flap  with  its  dermal  layer  towards  tlie  inside  (to- 
wards the  audittu-y  canal)  and  suture  to  margin  of  listnla.  ( Kig. 
41)1 1. ) 

5.  Close  newly-rornietl  defect  liy  iirst  loosening  its  margin  (Fig. 
401).  snlise(piently  either  cover  the  turned-in  llap  with  skin  graft  or 
allow  it  to  gi;undate  and  cii-atrize.  It  hecomes  necessary  at  times  to 
make  .secondary  corrections  at  the  pediide  jiortion. 

Goldstein's  Operation. 

1.  l.dOMii  liic  !ii,iiL;in>  aliout  the  listnla  freely  on  the  cartilage  as 
well  as  on  the  mastoid  side,  and  freshen  up  the  margins. 

'2.     Make  lateral  incisions  to  allow  free  coaptation  of  the  margins 

of  the  listnla.     (Fig.  4l)-J.) 

:;.     Clr.se  hy  means  of  .Mi.hel'>  <lip>.     (  Fi-   4(i;!.) 

4.     .\llow   the  defects  created   li\    I'ounler  in<-isions  for  relaxation 

to  yranulati'. 

Ear  Prothesis. 

As  in  nasal  defoi  inities,  there  are  times  when  the  local  as  well 
as  tho  general  loiidition  does  not  warrant  an  operation  of  magnitude; 
under  sti<di  ciiinm-lances  much  lietter  results  are  (»litaiinMl  hy  the 
use  of  a  Well  littini;  arlilicial  ear. 


380  (iiM;i;Ari\K,  snaiKitv  f)i"  tiik  nose,  tiiuoa'I'.  ami  kak. 


Fiji'.    :!!».' 


Fig.   39(5.  Fig.    307. 

Tlic  Trautniaiiii  cipcniliuii  for  clcisuro  of  po.stericir  ilcficioiicies. 


I'LASTIC    Sll!(;r.i;V    dl'    TIIK    NdSK    AM)    KAIt. 


381 


FiK.  -M'X 


^ 


f 
■  ^ 


Fig.  400. 
Tlip  von   Mii.-w-tigModrlioff  oiHTiition   for   post' 


382 


H'KI'.A'I'IVK    smcKKV    OK    T 1 1  K    XOSK.    TllltOAT,    AMI    KAII. 


It  is  necessary  a)  limes  tn  shape  tile  stuiup  i-eiiiaiiiiiiti'  so  that  tlie 
aftilieial  ear  iiia\  lit  and  liold  iiroperly.  Ayain  tliere  may  lie  no  ex- 
ternal part  at  all,  ami  then  it  niay  l)e  necessary  to  constrnct   iVom  the 


Fiy.  402.  Fis.   -408. 

Goldstein's   retio-aurioiilar   plastic. 


Fit;.  J'J-l- 
Celluloid   artifieial    eai'. 


tissues  siUTOunilini;  the  area  of  the  auditory  meatus  a  ])lace  for  the  at- 
laehnieut  of  tlie  prothesis.    Fii^'.  -KI4  illustrates  a  celluloid  aititicial  ear. 


I'l.ASTic  sii!iiKi;v  ur  Till-:   nusk  anh  kai:.  'AS'.', 

Neuroplasty  for  Facial  Paralysis. 

Till'  various  plastic'  oprratioiis  mi  llir  lacial  iici\c  arc  pfrl'nniK'il 
for  till'  iMirposc  of  ri'i'stalilisliiiiii-  tlic  fiiiirtioii  of  llir  iicri|ili(ial  liraiiclics 
of  the  facial  ih'iac  after  it  has  left  llir  styloiiiasloiil  fniaiiicii,  ])y 
traiis|>laiitiiin'  tliis  ilistal  I'lul  into  aiioliicr  motor  iiir\c  or  ajiprox- 
iiiiatiiii;-  it  diri-i'tly  to  tin*  I'l'iitral  or  proximal  portion  of  sii«li  a  ncrvi". 
All  liraiK'lii's  of  tlii'  facial  iirrvi'  jfivni  olT  witiiiii  tin-  tciii|iiii;il  Ixmi'  arr 
not  iiitliii'in'cd  hy  anastomosiiiu-  prot'i'duri's.  Tlii'  dinci  upair  nf  the 
sovi'i-i'il  farial  iii-rvi'  is  not  fonsiili'ri'il  in  this  discussion  of  iiiMiroplast\ . 
Till'  mi'thods  I'lnployi'd  Iii-ri'tofori'  an-: 

1.      facial  s|iiiial  accessory  end  to  end  anastomosis. 

'2.  Facial  hypoglossal,  end  (facial  iici\c)  to  side  (of  hvperulos- 
sal). 

'A.     Faoial-hyi)o.a:liissal.  end  to  I'lid. 

4.  Facial-spinal  accessory  and  dcsci'iidcns  hypoiilossi  spinal  ac- 
cessory anastomosis. 

•  ).     Facial-.iilossopliaryiiifcal  anastomosis. 

The  jiriuciples  iinderlyinir  neiiroiilastic  surucry  arc: 

1.  The  approximatini;'  iierx'es  innst  lie  under  alisoliilely  no  ten- 
sion. 

■J.  The  neural  >tructiire>  of  oih'  iier\c  >li()uld  lie  in  cdutaci  with 
the  neural  structures  of  the  opjiosite  nerve.  (This  is  parliciilarly 
necessary  in  the  end  to  side  methods.) 

3.  Sutiirinn-  must  lie  done  with   the  linest   of  iiiatciial  and  under 
li'reat  care  (not  so  iiian\    sutiii-es  liein^'  used  as  in  ciKJanuci-  -IraiiLiula 
tioii  I. 

4.  The  anastomosed  nerves  sliould  lie  >urroiinded  with  muscle 
tissue  or  Cardfile  memhrane,  to  pre\ciil  Inn  -teat  a  cicatricial  forma- 
tion alioiit  them. 

').     Alisolute  asepsis  is  necessary  to  ohtaiii  a  i::ood  result. 

(i.  Adjunct  treatment  such  as  electricity,  massaiic.  tonics,  etc., 
followinif  the  operation  hastens  reco\cr\.  tln^  liiiie  clcpcndiim  on  the 
deirree  of  muscular  atrojihy  which  preceded  the  niiciatioii. 

7.  ( 'orrect  diairnosis  liefore  the  oiieralinn  a>  to  the  reaction  to 
defeneration  is  very  important,  so  as  to  he  sure  that  if  a  jierfect 
anastomosis  operation  is  performed  and  union  is  ahsoliilely  )ierfect, 
a  :;ood  result  is  |iossilile;  otherwise  this  excellent  therapeutic  pro 
cedure  would  lie  discredited,  as  the  luuscle  wouhl  not  he  susceplilih' 
of  motion  in  >pite  of  the  nnimpedi'd  iiei\c  slimulus. 


384 


()I'KI;aTIVK    sriKiKIIV    ok   TIIK    XOSK,    Tili;i)AT.    AXD    EAK. 


Spino-Facial  and  Periphero-Spinal  to  Descendens  Hypoglossi 
Anastomosis.* 

1.  Make  a  V-slia})ed  incision,  one  liraiicli  of  tlic  ^'  ciitrnii;-  in  front 
o['  the  ti-a,u'ns,  the  other  back  of  the  eai-  on  the  line  witli  the  ti-a,niis. 
The  stalk  of  tlie  Y  is  directed  forward  and  (hiwnward,  in  front  of  the 
stenioniastoid,  for  al)ont  tliree  inches  in  lenntii.  Tliis  incision  goes 
thron,i;ii  skin  and  suiierfieial  fascia,     (l^'ig.  4(15.) 

1^.  Dissect  bluntly  down  to  the  muscles  and  expose  the  i^osterior 
border  of  the  ])arotid  yiand. 

o.  l^levate  the  lobule  of  the  ear,  draw  forward  tlie  parotid  gland 
and  dissect  down  into  the  narrow  sjiace  between  the  anterior  borch'r 


Fig.  405. 
Incision  for  .s|iino-f;icial   ana.stoniosis 


of  the  mastoid  and  the  ]>osterior  boi-uei-  of  the  ranuis  of  the  lower 
jaw.  Here  locate  the  facial  nerve  in  its  course  from  the  stylomastoid 
foramen  towards  the  posterior  Ixirder  and  the  under  surface  of  the 
parotid  gland. 

4.  l^lace  a  ligature  (but  not  Wvd)  ai-onnd  it  for  subsequent  identi- 
hcation  and  leave  tliis  field  of  operation  f<u'  the  time  lieing  for  the 
location  of  the  other  nerves.  (Fig.  40().) 

.").  Find  the  spinal  accessory  nerve,  wliieh  is  on  the  line  from  the 
angle  of  the  lower  jaw  backward,  where  it  pierces  the  fascia  of  the 
sternomastoid  muscles. 

6.  Place  a  suture  about  it  for  the  same  imrpose  as  in  the  facial. 
(Fig.  40(j.) 


♦Contributed    by   W.   W.   Grant.   M.D..    Dinvcr. 


ri.ASTir  srr.di'.iiv  ni-  tiik  xosk  an'h  kak. 


:j8r> 


7.  K\|i(i>c  till'  li\  |i(ii:ltiss;il  whii-li  lies  in  lliis  iciiioii.  Jii-t  win  ic- 
tlic  ofci]iitiil  artiTv  is  nivi'ii  oil"  troiii  the  cxIitii.iI  cnrdtid,  .■ilmiit  the 
tH'iitiiil  tt'iiilitii  ol'  till'  (ii.yfiistric  imisc'ii'. 

S.  Cut  till'  iliuastrif  iiniscli«  posti-rior  to  its  cciilral  tcinl(iii  aiiil 
rollec't  tins  posti-rior  liclly  liackwavl. 


Vis.  «<••!. 
Spino-fn<-iaI    luul    poriiilipro.xpiiinl    to   dosrcndcns    liypuRloosi    niinMoniosis. 

II.  I.oratc  till'  (It'sci'iKlcus  iiypnyflossi  at  this  point  as  it  leaves 
till'  liypdiilnssiil  and  i)assi's  (Inwnwanl  on  tlic  sjicatli  of  tlii'  common 
carotid  artery.    I'lace  a  tlircai!  aliont  tliis  ncrvc  also.     {V\<r.  40(i. ) 


386  (iin;i;.\Ti\  K  sikukkv  ok  the  nose,  throat,  and  kai;. 

10.  Go  back  to  the  racial  ucixc,  draw  i1  out  so  as  1o  lie  able 
to  roach  the  end  that  comes  from  tlic  styUmiastoid  t'oramni  and  with 
a  ]iaii-  of  sU'iidcr  scissors  sever  it  close  to  this  foramen  and  pnll  out 
this  end  of  tile  lu'rve. 

11.  I'ull  on  tJH'  s|Mnal  accessory  and  sever  it  .just  hefoi-e  it  enters 
tlie  sternomastoid  muscle,  making  sure  before  it  is  severed  that  a 
long  enough  segment  may  be  drawn  to  unite  -with  the  facial  stump 
witlioiit  occasioning  any  tension  when  their  ends  are  united. 

}'2.  Have  an  assistant  hold  both  ends.  Tlien  cut  off  the  spinal 
accessory  and  the  peripheral  end  of  the  facial  in  close  and  exact 
approximation,  tlie  ojiei'ator  suturing  them  with  line  linen  thread,  and 
using  a  small    innnd  needle.     ( )ne  suture  is  to  lie  made  at   each   side. 


Fig.  407. 
Beck's  nerve  tracing  forceps. 

possibly  including  some  ner\e  fibres,  and  another  supporting  suture 
through  the  neurilenuna  only  on  tlie  under  siTrface.  The  sutures  are  tied 
only  moderately  tight. 

13.  To  prevent  cicatricial  constriction,  place  some  Cargile  mem- 
brane at  the  point  of  nerve  union  about  this  anastomosis. 

14.  Now  sever  the  descendens  liypoglossi  by  drawing  on  the 
thread  fully  three-fourths  of  an  ineli  lielow  where  it  leaves  the  hypo- 
glossal, and  turn  this  cut  end  njiward. 

15.  Approximate  this  end  of  the  descendens  liypoglossi  and  the 
peripheral  end  of  the  spinal  accessoiy  with  the  same  technic  as  was 
nsed  on  the  facial  nerve. 

16.  Reunite  the  digastric  muscle  and  close  the  wound  without 
drainage. 

Facial-Spinal  Accessory  Anastomosis. 

].  Make  an  incision  through  the  skin  facia  from  behind  the  ear 
forward  and  downward  along  the  anterior  border  of  sternomastoid 
muscle,  to  about  the  level  of  the  thvroid  cartilage. 


ri.ASTIC    Sri!t;KI!Y    (IK    TlIK    XdSl';    ANU    I'.AK. 


3ST 


L'.  lu'tr.ii't  Mini  liihl  tlif  s|iiiial  iicc.-ssnry  iht\c  :is  it  pirrrcs  tli<' 
stcriioiiiJistoiW  imisclc. 

'A.  Dissi'ct  mikI  rctnict  fnrw.-ii.l  i.v.t  tlic  lower  Jaw,  cxiKisini;  tlir 
]>i\rotitl  liiand  (jiDstcrior  Itordcr). 

4.  LtH-atf  till'  facial  iutv  i'  as  it  ciitiTs  this  ^laiid. 

.').  Follow  it  Itclow  tln"  i-artilayiiioiis  imrtioii  of  tlu>  oxtonial  :\n 
ditory  canal  down  hcfwi'cii  tlu"  ixistcrior  liordcr  of  the  i-ainus  of  the 
lower  jaw  ami  tlu-  aiiterior  lioriler  of  the  mastoid  [iroci'ss. 

(i.  It  may  lu'  ncci'ssaiy  to  divide  the  posti'iior  lielly  of  the  diuastiie 
imisele.  Ketraet  the  styloliyoid  iinisclo  and  i»ass  about  the  nerve  the 
author's  nerve  tracinf?  forcejis.  (Fi.a;.  407.)  Follow  the  nerve  to  the 
stylomastoid  foramen,  which  is  hehiiKl  the  styloid  jiroci'>>.  and  c-h>M-  on 
the  nerve. 

7.  Steadily  jiull  the  ihtvc  out  of  ilir  ma^Inid  canal  ( >tylomastoid 
foramen)  ami  keep  the  forceps  attached  to  the  nerve. 

5.  AVithdraw  iis  much  of  the  spinal  accessory  nerve  as  is  neces- 
sary to  make  an  easy  approximation  w  itli  tin'  di>M(ti'd  lacial  nerve. 

9.  Trim  the  facial  nerve  end  sijuarely  to  lit  tlic  >pinal  ac<'essury 
and  suture  the  two  end  to  end. 

10.  Three  sutures  are  placed,  i-oin.i;'  throni^li  the  neurilennna  and 
lakinu  in  a  few  of  the  axis  cylinders.  An  additional  sui)])ortin;i  snturc 
(continnous)  takes  in  oidy  the  sheath  of  both  the  nerves. 

11.  ^lake  a  slit  or  pocket  into  the  postei-ior  Itelly  of  the  iliiiastric 
uni-sele  (if  it  is  divided  it  should  first  lie  nnitidi,  or  place  a  la>ir  of 
C'ar.iiile  membrane  about  the  anastomosis. 

IL'.     Cl.^e  wonml. 

Facial-Hypoglossal  End  to  Side  Anastomosis. 

1.  Imi-r  the  skin,  fascia  and  plaly>rna.  beuinnin^'  behind  the  ear 
and  carrying'  the  .'nl  downuarcl  an.!  then  forward  towards  the  tliyi-oid 
oartilaire. 

2.  Ketracing  the  tissues,  the  hypo-rlossal  nerve  is  located  by 
drawing:  up  the  digastric  muscles  i)osterior  to  the  sternomastoid  where 
the  sheaths  of  the  great  vessels  lie.  On  the  level  of  the  thyroid  car 
tilage,  where  the  carotid  ai-tery  divides  into  the  external  and  internal 
branches,  the  hypoglossal  ner\c  will  b.'  seen  at  the  )ioint  of  crossing 
of  the  occiiiital  and  the  inteinal  carotid  arteries.  Here  it  turns  for- 
ward and  lies  on  the  mylohyoid  muscle. 

."..      Fxiio.se  the   hypoglossal   nerve  at    the  point   closest    to  tile   facial 

nerve. 

4.  Locate  the  facial  nerve  as  in  the  facial-spinal  accessory  anas- 
tomosis, and  draw  it  out  in  the  manner  described  above  from  the  stylo- 
mastoid foramen. 


388 


ii'K.i;ATiVK  srr.cKnv  ok  tiik  xosk,  tiiiioat,  axd  kar. 


").  Trim  the  facial  stiiin)i  in  such  a  nianiici-  as  to  strip  tlio  iiiajoi'- 
ity  of  the  axis  cyliiiders  of  tlieir  sheaths  for  ahoiit  three  lines. 

6.  Place  three  sutures  tliroiiuli  the  stiiiiiii,  thus  gettin.n-  it  ready 
to  join  ^vitll  tlie  hypoglossal  nerve. 

7.  Make  a  small  buttonhole  in  tlu'  exposed  liyjiou'lossal  nerve  at 
tlu'  point  mentioned  in  division  .'1,  paraUel  to  the  course  of  the  nerve 
and  on  its  upper  border,  to  admit   the   prepai'ed  facial  stum]).     Tt  is 


Pcrotid 


F<5,cia1  nerve  im 

,,-  planted  end  to 

Side   in  Irypo- 


Posterior  belly 
of  did,<i3tric  cut 
c>.nd  reflected 


well  to  enter  this  buttonhole  slit  witli  a  tine  pair  of  scissors  and  cut 
a  few  axis  cylinders  transversely  within  the  sheath  in  order  to  get 
direct  contact  with  the  facial  axis  cylinders  and  thus  obtain  a  more 
rapid  regeneration. 

8.  Pass  the  already  prepared  sutures  of  the  facial  stumj)  through 
tlie  slit  in  the  hypoglossal  nerve  from  Avithin,  outward,  one  on  each 
side  and  the  third  at  one  end.     The  tving  should  be  done  by  the  oper- 


PLASTK'    Sl"l!(ii:i;V    Ol'    TIIK    XOSK    AND    EAU. 


389 


ator  while  the  as.sist.-int  l<cf|(s  the  slil  (i|icii  with  a  line  |i;iii-  i>\'  rdircps 
(spriii.ir)  Jiiid  liolds  the  I'iiciiil  slump  stciuly  in  the  slit.  Aiiotlicr  sup 
IHirtinjr  suture  surrounds  tliis  anastonidsis  in  the  sanir  luanuer  as  in 
the  spinal  aecessory  pmcethire.     (Fig.  4(IS. ) 

9.  The  same  pr<)ee(hire  as  in  the  t'aeial  spinal  aeeessorv  is  i\>\ 
lowed  in  the  jirevention  of  eicatricial  forniatidii  alumt  the  iniicm,  as 
is  also  in  the  closure  of  the  i'\tcrna]  wound. 

Facial-Hypoglossal  End  to  End  Anastomosis. 

1.     The  same  proeeilurc  as  in  ihc  end  In  >ii|c  n|irr;itiiin  up  tn  the 


Parotid 
a,le>nd 


Fo>cie>l  nerve  An- 
astomosed  end 
to  end  with   bypo- 


Desccndens 
hypo^lossi 


Postet-ior  dift- 
i  /'  ^O'Stric   cut  cind 
///      reflected 

I 


Fif,'.    l(1!i. 
I'ai-iiilliypoglo.ssjil    cml    tn   mil    !Ui!LHfoniosi.s. 

l)oiut  of  union,  except  that  the  hy|iofrlossal  is  not   pnp.ncd   m.  cIcm- 
to  the  facial  nerve.     (Fig.  4(l!>. ) 

2.  Follow  the  hyj^oglossai  nerve  nearer  to  the  front  as  it  enters 
the  flooi-  of  the  mouth. 

3.  Sever  the  hypoglossal  and  tuni  it  l)aek  to  join  it  with  t!ie 
faeial  nen-e,  which  has  also  lieen  prejiared  as  in  the  other  two  pievions 
jiroeedures. 


390  OPEKATIVE    STIUiEIlY    OF   THE    XOSE,    THROAT,    AXD   EAR. 

4.  The  union  and  iiiauageuieut  of  the  anastomosis  and  tlie  wound 
arc  siil)ject  to  the  same  i)rocedure  as  in  the  facial-spinal  accessory 
operation. 

Myeloplasty  for  Facial  Paralysis. 

In  eases  of  congenital  I'aeial  i)aralysis,  or  in  jx'rmaneiit  i>aralysis 
in  wluch  the  peripheral  branches  of  the  facial  nerve  arc  imbedded  iu 
cicatricial  connective  tissue,  or  Avhen  the  paralyzed  muscles  of  the  face 
supplied  by  the  seventh  cranial  nerve  are  completely  atropliied  and  do 
not  react  to  the  electric  currents,  or  finally  if  for  any  reason  tlie  hypo- 
glossal or  accessory  nerves  are  not  accessible  and  the  neuroplastie 
operation  cannot  be  performed  for  any  other  reason,  the  masseter 
muscles  may  be  used  to  obtain  a  straighter  face.  The  associated  move- 
ments following  this  operation  arc  oljjcctional.  These,  however,  do  not 
persist,  for  the  patients  re-educate  that  particular  part  of  the  uiasseter 
muscle  which  causes  facial  expressions. 

Teclinic. — Tender  local  or  general  anesthesia  make  an  incision 
along  the  posterior  border  of  the  ramus  of  the  lower  jaw.  The  tissues 
are  dissected  forw^ard  until  part  of  the  masseter  muscles  is  reached. 
These  are  now  separated  from  their  attachment  to  the  ramus  of  tlio 
jaw  and  the  lower  boi'der.  A  sort  of  a  tunnel  is  now  made  ^vitli  a  ])air 
of  Mayo's  scissors,  spreading  the  tissues  rather  tlian  cutting  thorn, 
until  one  reaches  the  external  angle  of  the  month.  It  is  important 
not  to  go  too  high  in  order  not  to  Avound  the  duct  of  the  parotid  gian<l. 
As  the  angle  of  the  mouth  is  approached,  care  must  be  taken  not  to 
wound  the  facial  artery.  The  facial  vein  must  sometinu's  be  ligated. 
Great  care  is  to  be  exercised  not  to  jjenetrate  through  the  mucous 
membrane  of  the  mouth  or  the  skin  externally.  The  masseter  muscle.^"- 
already  sevei'ed  are  now  armed  on  two  silkwoi-m  gut  sutnres,  Avith 
very  short  curA^ed  needles,  one  on  each  end  of  the  tliread  so  as  to  have 
four  needles  in  all.  One  thread  is  noAV  passed  close  to  tlie  upper  lip, 
through  the  subcutaneous  tissue  and  skin,  Avhile  the  second  thread 
is  placed  close  to  the  loAvcr  li]i.  Tliese  sutures  are  tied  oA^er  a  piece 
of  gauze  to  prcA^ent  their  cutting  in.  The  Avouud  is  closed  completely 
Avithout  drainage. 

During  the  next  three  Aveeks  the  patient  takes  only  li(iuid  diet  in 
order  not  to  use  the  masseter  miiscles.  The  stitches  holding  them  are 
remoA'ed  at  the  end  of  ten  days,  as  are  also  those  of  the  incision. 


UNIVERSITY  OF  CALIFORNIA   LIBRARV 

Los  Angeles 
This  book  is  DUE  on  Ihe  last  date  stamped  below. 


A.!      4   <-^ 


BIOMEO  LIB. 

SEP2  9RECD 


Form  L9-Series  4939 


3  1158  00883  3195 


D  000  137  852  u 


